CCMC Utilization Management 1 — Questions and Answers
Question 1: What is the primary purpose of utilization management in case management?
- To maximize hospital revenue
- To ensure appropriate use of healthcare resources while maintaining quality (Correct answer)
- To limit patient access to all specialty services
- To replace the role of the treating physician
Correct answer: To ensure appropriate use of healthcare resources while maintaining quality
Utilization management ensures healthcare resources are used appropriately and efficiently while maintaining quality patient care outcomes.
Question 2: Which type of utilization review involves evaluating the appropriateness of care BEFORE it is provided?
- Concurrent review
- Retrospective review
- Prospective review (prior authorization) (Correct answer)
- Focused review
Correct answer: Prospective review (prior authorization)
Prospective review, also called prior authorization, occurs before care is delivered to determine medical necessity and appropriateness.
Question 3: InterQual and Milliman Care Guidelines are examples of:
- Federal insurance regulations
- Evidence-based clinical criteria used in utilization review (Correct answer)
- Hospital billing code systems
- State licensing requirements for case managers
Correct answer: Evidence-based clinical criteria used in utilization review
InterQual and Milliman Care Guidelines are evidence-based clinical criteria tools used to assess medical necessity and appropriate level of care.
Question 4: When a payer denies a claim for lack of medical necessity, the case manager's FIRST step should be to:
- Immediately file a lawsuit against the payer
- Accept the denial and notify the patient to pay out of pocket
- Review the denial reason and gather supporting clinical documentation (Correct answer)
- Discharge the patient immediately from care
Correct answer: Review the denial reason and gather supporting clinical documentation
The first step after a denial is to review the reason and gather clinical documentation to support an appeal if appropriate.
Question 5: Concurrent utilization review is performed:
- Before care is authorized
- During the course of treatment or hospitalization (Correct answer)
- After the patient is discharged
- Only for outpatient services
Correct answer: During the course of treatment or hospitalization
Concurrent review occurs during an ongoing episode of care to assess continued medical necessity and appropriateness of the current level of care.
Question 6: Which organization accredits utilization review organizations (UROs) and sets standards for utilization management programs?
- CMS (Centers for Medicare & Medicaid Services)
- The Joint Commission
- URAC (Utilization Review Accreditation Commission) (Correct answer)
- AHIMA
Correct answer: URAC (Utilization Review Accreditation Commission)
URAC accredits utilization review organizations and establishes national standards for utilization management programs.
Question 7: A 'peer-to-peer review' in utilization management involves:
- Patients reviewing their own care decisions with a coordinator
- A treating physician speaking directly with a medical reviewer to discuss a denial (Correct answer)
- Case managers auditing each other's documentation for accuracy
- Insurance adjusters reviewing billing codes with the hospital
Correct answer: A treating physician speaking directly with a medical reviewer to discuss a denial
A peer-to-peer review allows the treating physician to discuss a utilization denial directly with the payer's medical reviewer to provide additional clinical context.
CCMC Utilization Management 1
What is the primary purpose of utilization management in case management?