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

Outlier cases exceed expected cost or length of stay benchmarks and often trigger additional review and intensive case management intervention.

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

Denial management programs track denied claims, identify root causes, pursue appropriate appeals, and implement process improvements to reduce future denials.

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

Comprehensive discharge planning, post-acute care coordination, and patient and caregiver education are the most evidence-based strategies for reducing preventable readmissions.

Question 4

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

Accepted Answer

Failure to provide a clinically recommended preventive screening

Answer

Underutilization occurs when clinically appropriate and necessary care is not provided — such as omitting a recommended cancer screening for an eligible patient.

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

Bundled payments provide a fixed amount for an entire episode of care, incentivizing providers to deliver efficient, appropriate care without unnecessary resource use.

CCMC - Commission for Case Manager Certification Practice Test

CCMC - Commission for Case Manager Certification Practice Test

CCMC Utilization Management 3