CCMC - Commission for Case Manager Care Delivery & Reimbursement Questions and Answers

Question 1

A case manager is working with a hospital that is reimbursed by Medicare under the Inpatient Prospective Payment System (IPPS).
The payment for a patient's stay is primarily determined by which of the following?

Accepted Answer

The patient's Diagnosis-Related Group (DRG).

Answer

The actual cost of the services provided during the inpatient stay.

Answer

The total number of days the patient remained in the hospital.

Answer

A fee-for-service schedule negotiated annually with the hospital.

Question 2

A patient with multiple chronic conditions is enrolled in a Medicaid Managed Care Organization (MCO). The MCO pays the primary care provider a fixed amount per member per month to cover all necessary services. This reimbursement model is known as:

Accepted Answer

Capitation

Answer

Fee-for-service

Answer

Bundled payment

Answer

Shared savings

Question 3

Which of the following best describes the primary goal of a Value-Based Purchasing (VBP) program in healthcare reimbursement?

Accepted Answer

To link a portion of provider payment to performance on quality and efficiency measures.

Answer

To increase the volume of services provided to maximize hospital revenue.

Answer

To establish a fixed case rate for every diagnosis, regardless of patient outcomes.

Answer

To eliminate the need for utilization review by pre-authorizing all services.

Question 4

A case manager is reviewing a patient's chart to ensure the current hospital admission meets the payer's criteria for medical necessity and level of care. This function is a core component of:

Accepted Answer

Utilization management

Answer

Discharge planning

Answer

Risk stratification

Answer

Patient advocacy

Question 5

A patient undergoes a total knee replacement. The hospital, surgeons, and physical therapists receive a single, predetermined payment that is meant to cover all services related to the surgery, hospitalization, and a 90-day post-acute care period. This payment model is an example of:

Accepted Answer

Bundled payment

Answer

Global payment

Answer

Fee-for-service

Answer

Per diem payment

Question 6

In a healthcare system moving towards alternative payment models, what is the fundamental difference between a fee-for-service (FFS) model and a prospective payment system (PPS)?

Accepted Answer

FFS pays based on the volume of services, while PPS pays a predetermined rate based on diagnosis or procedure.

Answer

FFS is used exclusively for outpatient care, while PPS is only for inpatient care.

Answer

FFS payments are determined by the patient's insurance plan, while PPS rates are set by the hospital.

Answer

FFS encourages shorter hospital stays, while PPS incentivizes longer, more comprehensive stays.