CCM Reimbursement and Utilization Management 5 — Questions and Answers
Question 1: What is the purpose of a 'remittance advice' (RA) sent by an insurer to a provider?
- To notify the provider of the patient's remaining deductible balance
- To explain the payment decisions made on submitted claims, including amounts paid, adjusted, and denied (Correct answer)
- To request additional clinical documentation before processing a claim
- To confirm that a prior authorization has been approved
Correct answer: To explain the payment decisions made on submitted claims, including amounts paid, adjusted, and denied
A remittance advice (RA) details how each claim was adjudicated, including payments, contractual adjustments, and denial reasons.
Question 2: Which federal act prohibits providers from knowingly submitting false or fraudulent claims to federal healthcare programs?
- HIPAA
- The False Claims Act (FCA) (Correct answer)
- The Stark Law
- ERISA
Correct answer: The False Claims Act (FCA)
The False Claims Act imposes civil liability on entities that submit fraudulent claims to government programs, including Medicare and Medicaid.
Question 3: A case manager notices a pattern of a physician ordering the same high-cost test for every patient regardless of diagnosis. This is MOST likely an example of:
- Evidence-based practice
- Overutilization (Correct answer)
- Underutilization
- Resource stewardship
Correct answer: Overutilization
Ordering tests indiscriminately without clinical indication represents overutilization, which drives up costs without improving outcomes.
Question 4: Which of the following is a core difference between Medicare Part C (Medicare Advantage) and traditional Medicare?
- Medicare Advantage is funded by state governments while traditional Medicare is federally funded
- Medicare Advantage plans are offered by private insurers approved by CMS and may include additional benefits beyond Parts A and B (Correct answer)
- Medicare Advantage does not cover hospital inpatient stays
- Traditional Medicare requires a primary care physician referral to see specialists
Correct answer: Medicare Advantage plans are offered by private insurers approved by CMS and may include additional benefits beyond Parts A and B
Medicare Advantage plans are private insurance alternatives to traditional Medicare that often include extra benefits like dental, vision, and Part D drug coverage.
Question 5: When a managed care organization contracts with a hospital to pay $1,200 per inpatient day regardless of diagnosis or services provided, this arrangement is called:
- Capitation
- Per diem reimbursement (Correct answer)
- DRG-based payment
- Fee-for-service
Correct answer: Per diem reimbursement
Per diem reimbursement pays a flat daily rate for inpatient care, incentivizing shorter lengths of stay since each additional day pays the same rate.
Question 6: Under the ACA's essential health benefits (EHBs), which of the following services MUST be covered by individual and small-group health plans?
- Elective cosmetic surgery and vision correction procedures
- Emergency services, mental health services, and preventive care (Correct answer)
- Experimental treatments and off-label drug use
- Long-term custodial nursing home care
Correct answer: Emergency services, mental health services, and preventive care
The ACA mandates coverage of 10 essential health benefit categories, including emergency services, mental health and substance use disorder services, and preventive care.
Question 7: A case manager learns that a patient's claim was denied because the provider was not in the insurer's network. The patient visited this provider due to a true emergency. Which federal law most likely protects this patient from higher out-of-network cost-sharing?
- ERISA
- The No Surprises Act (Correct answer)
- COBRA
- The Stark Law
Correct answer: The No Surprises Act
The No Surprises Act protects patients from unexpected out-of-network charges for emergency care and certain non-emergency services at in-network facilities.
CCM Reimbursement and Utilization Management 5
What is the purpose of a 'remittance advice' (RA) sent by an insurer to a provider?