CCM - Certified Case Manager Exam Certified Case Manager Reimbursement and Utilization Management 1

Question 1

A health plan pays a primary care physician a fixed monthly fee per enrolled patient, regardless of how many services that patient uses. This payment arrangement is called:

Accepted Answer

Capitation

Answer

Capitation is a payment model in which a provider receives a set amount per member per month (PMPM) in exchange for agreeing to deliver covered services to that member, shifting financial risk from the payer to the provider.

Question 2

A Medicare beneficiary is kept in a hospital bed and receiving tests and treatment, but the physician has not written a formal inpatient admission order. This patient is most likely classified under which status?

Accepted Answer

Observation status

Answer

Observation status is an outpatient classification. Medicare bills observation stays under Part B, not Part A, which means the beneficiary may face higher cost-sharing and the stay does not count toward the three-day inpatient requirement needed to qualify for SNF coverage.

Question 3

When a claim is denied by a managed care organization, the case manager's first recommended step in advocating for the patient is to:

Accepted Answer

Initiate a formal internal appeal using clinical documentation to support medical necessity

Answer

The internal appeal process is the required first step before escalating to external review. Case managers strengthen appeals by submitting clinical notes, evidence-based guidelines, and peer-reviewed literature that support the medical necessity of the denied service.

Question 4

A patient covered by both a group employer health plan and a spouse's employer health plan needs surgery. The case manager must determine which plan pays first. This process is known as:

Accepted Answer

Coordination of benefits (COB)

Answer

Coordination of benefits (COB) is the process used when a patient has dual coverage to determine which plan is primary (pays first) and which is secondary (pays remaining costs), preventing total reimbursements from exceeding 100% of the claim.

Question 5

Under a value-based purchasing (VBP) program, a hospital's Medicare reimbursement is adjusted based on:

Accepted Answer

Performance on quality metrics such as patient outcomes and satisfaction scores

Answer

Value-based purchasing ties a portion of hospital Medicare payments to performance on quality and safety measures—including clinical process measures, patient experience scores, and outcomes—shifting incentives from volume to value.

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Practice Test

CCM - Certified Case Manager Exam Certified Case Manager Reimbursement and Utilization Management 1