Care Delivery & Reimbursement Methods
(Comprises 31% of the Exam, approximately 47 questions)
A case manager must have broad knowledge of care delivery and reimbursement methods to perform her job effectively. She must understand the clinical and financial resources available to her client, as well as the eligibility criteria for receiving those resources. This will enable her to ensure the client receives the most appropriate care in a cost- effective manner.
- Alternative care facilities (e.g., assisted living, group homes, residential treatment facilities)
- Management of acute and chronic illness and disability
- Medication therapy management and reconciliation
- Palliative care and symptom management
- Roles and functions of other providers
- Roles and functions of case managers in various settings
- Transitions of care / transitional care (new)
- Healthcare delivery systems
- Healthcare providers (new)
- Interdisciplinary care team (ICT)
- Levels of care and care settings
- Adherence to care regimen (new)
- Case management process and tools (new)
- Coding methodologies (e.g., Diagnosis-related group [DRG], Diagnostic and Statistical Manual of Mental Disorders [DSM], International Classification of Diseases [ICD], Current Procedural Terminology [CPT]) (new)
- Cost containment principles
- Factors used to identify client’s acuity or severity levels
- Financial resources (e.g., waiver programs, special needs trusts, viatical settlements)
- Goals and objectives of case management practice
- Hospice, palliative, and end of life care (new)
- Insurance principles (e.g., health, disability, workers compensation, long term care)
- Managed care concepts
- Management of clients with multiple chronic illnesses
- Military benefit programs (e.g., TRICARE, VA, CHAMPVA, TRICARE for Life) (new)
- Models of care (e.g., patient centered medical home [PCMH], accountable care organization, health home, special needs plan [SNPs], chronic care model) (new)
- Negotiation techniques
- Physical functioning and behavioral health assessment
- Private benefit programs (e.g., pharmacy benefits management, indemnity, employer-sponsored health coverage, individual-purchased insurance, home care benefits, COBRA)
- Public benefit programs (e.g., SSI, SSDI, Medicare, Medicaid)
- Reimbursement and payment methodologies (e.g., bundled, case rate, prospective payment systems, value-based purchasing)
- Utilization management principles and guidelines