CCM Resource Management & Utilization 3

Question 1

Which federal law established the Prospective Payment System (PPS) for Medicare inpatient hospital stays, directly impacting resource utilization?

Accepted Answer

The Social Security Amendments of 1983

Answer

The 1983 Social Security Amendments created the DRG-based Prospective Payment System, incentivizing hospitals to manage resource use and reduce unnecessary inpatient days.

Question 2

A case manager is evaluating whether a patient meets criteria for acute inpatient admission versus observation status. Which tool is MOST commonly used for this determination?

Accepted Answer

InterQual or Milliman Care Guidelines

Answer

InterQual and Milliman Care Guidelines are evidence-based clinical criteria tools used to determine appropriate level of care and medical necessity.

Question 3

What is the primary goal of a disease management program from a resource utilization perspective?

Accepted Answer

To reduce complications and hospitalizations through proactive chronic disease monitoring

Answer

Disease management programs target high-risk chronic disease patients to prevent acute exacerbations, reduce costly hospitalizations, and improve health outcomes.

Question 4

In a value-based care model, case managers are MOST focused on:

Accepted Answer

Achieving quality outcomes while managing cost efficiency

Answer

Value-based care aligns financial incentives with quality and efficiency, making cost-effective, outcome-driven resource use the central case management priority.

Question 5

A patient with a complex chronic condition is being discharged from the hospital. Which post-acute resource is MOST appropriate for a patient requiring daily skilled nursing care but not 24-hour medical supervision?

Accepted Answer

Skilled nursing facility (SNF)

Answer

A skilled nursing facility provides daily skilled nursing and therapy services for patients who are medically stable but not yet ready for home, making it the appropriate step-down option.

(CCM) Certified Care Management Professional Practice Test

(CCM) Certified Care Management Professional Practice Test

CCM Resource Management & Utilization 3