CCMC Utilization Management 3

Question 1

Under the utilization management framework, an 'outlier case' typically refers to:

Accepted Answer

A case with unusually high cost or resource utilization compared to benchmarks

Answer

A patient who refuses all recommended treatment options

Answer

A patient who transfers care to a provider in another state

Answer

A case involving pediatric patients under age five only

Question 2

The purpose of a 'denial management' program in utilization management is to:

Accepted Answer

Track, analyze, and reduce inappropriate claim denials through appeals and process improvement

Answer

Prevent patients from filing appeals for coverage decisions

Answer

Eliminate the need for prior authorization across all services

Answer

Require physicians to preauthorize all specialist referrals independently

Question 3

Which utilization management strategy is MOST effective at reducing preventable hospital readmissions?

Accepted Answer

Robust discharge planning with post-acute care coordination and patient education

Answer

Limiting all post-discharge follow-up appointments to reduce costs

Answer

Extending inpatient stays for all patients regardless of medical necessity

Answer

Transferring all complex patients to long-term care facilities upon discharge

Question 4

Which of the following is an example of underutilization in healthcare?

Accepted Answer

Failure to provide a clinically recommended preventive screening

Answer

Extended inpatient stays beyond what medical necessity supports

Answer

Excessive laboratory testing beyond what the diagnosis requires

Answer

Requesting unnecessary specialist referrals for minor complaints

Question 5

In the context of utilization management, 'bundled payment' reimbursement creates an incentive for providers to:

Accepted Answer

Use resources efficiently and avoid unnecessary services within the episode of care

Answer

Maximize the number of procedures performed per episode

Answer

Extend hospital stays as long as possible to recoup fixed costs

Answer

Order as many diagnostic tests as possible to ensure thorough documentation

Question 6

When a health plan issues a 'Notice of Non-Coverage' (NONC) to a Medicare beneficiary, this is primarily required to:

Accepted Answer

Notify the patient that coverage for a service is ending and explain their right to appeal

Answer

Inform the patient that their health plan is being terminated

Answer

Explain the patient's prescription drug benefits and formulary tiers

Answer

Detail the provider's billing practices and balance billing policies

Question 7

Which metric is MOST commonly used to evaluate utilization management effectiveness in an inpatient setting?

Accepted Answer

Average length of stay (ALOS) compared to geometric mean length of stay (GMLOS)

Answer

Patient satisfaction scores from post-discharge surveys

Answer

Total number of licensed beds available in the facility

Answer

Number of full-time physicians credentialed at the hospital