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Risk Adjustment Data Element - CORRECT ANSWERS ✔✔Age, Gende, Socioeconomic status, Disability status, Insurance status(Medicaid, dual-eligible,) Claims data elements such as procedure codes, place of service codes, special patient-specific conditions hospice, ESRD RAF - CORRECT ANSWERS ✔✔Risk Adjustment Factor Scores Three main types of reviews - CORRECT ANSWERS ✔✔Retrospective, Concurrent and prospective Retrospective - CORRECT ANSWERS ✔✔reviews are performed after the information has been reported and in risk adjustment these are prior years dos Concurrent reviews - CORRECT ANSWERS ✔✔performed ongoing as patients are seen prior to reporting and in risk adjustment the current year Prospective reviews - CORRECT ANSWERS ✔✔will effect the next year and not the current year where payment is concerned. They are used to forcast
Types of Risk Adjustment Models(HHS) - CORRECT ANSWERS ✔✔HHS hEALTH AND HUMAN SERVICES hIERARCHICAL CONDITION(Commercial, individual and small grooup Types of Risk Adjustment Modles(CDPS) - CORRECT ANSWERS ✔✔Chronic Illness and Disability payment systems(Medicaid) Types of Risk Adjustment Models(HCC-C) - CORRECT ANSWERS ✔✔Hierarchical Condition Category, Part C Types of Risk Adjustment model (DRG) - CORRECT ANSWERS ✔✔Diagnosis Related Group (Inpatient) Types of Risk Adjustment model (ACG) - CORRECT ANSWERS ✔✔Adjusted Clinical Groups(Outpatient) Prescription based program risk adjustment examples:UCSD - CORRECT ANSWERS ✔✔Medicaid Rx(UCSD) Prescription based program risk adjustment examples(Dxcg) - CORRECT ANSWERS ✔✔RxGroups(DxCG) Prescription based program risk adjustment examples(HCC-D) - CORRECT ANSWERS ✔✔Hierarchical Condition Category, Part D(HCC-D
malunion fracture - CORRECT ANSWERS ✔✔a healed fracture in a undesirable position resulting in a deformity or crooked limb. nonunion fracture - CORRECT ANSWERS ✔✔fracture is not healing New bone tissure is not growing to bridge the gap between the broken bones FFS Normalization adjustment - CORRECT ANSWERS ✔✔CMS payments are based on a population with an average risk score Special population for normalization factores - CORRECT ANSWERS ✔✔Pace Mode, ESRD and Part D History of CDPS - CORRECT ANSWERS ✔✔Began using RA in 1996 utilizing claims from disabled beneficiaries information from the disability payment system from Colorado, Michiganm Missouri, New York, and Ohio Star Ratings - CORRECT ANSWERS ✔✔Medicare Advantage plan would received a bonus if they receive 4 or more stars in 5 star quality ratings 5 star - CORRECT ANSWERS ✔✔Excellent performance 4 star - CORRECT ANSWERS ✔✔Above Average Performance
3 star - CORRECT ANSWERS ✔✔average performance 2 star - CORRECT ANSWERS ✔✔Below average performance 1 star - CORRECT ANSWERS ✔✔Poor Performance Part C Plan - CORRECT ANSWERS ✔✔Domain 1 Staying Helathy Screenings, test, and vaccines (7 measures Domain 2 Managing Chronic (Long Term) Conditions (12Measures) Domain 3 Member Experience with Health Plan (6 measures) Domain 4: Member complaints, problems getting service and improvement in the Health Plan's Performance (4 measures) Domain 5 Health Plan customer service (3 measures Part D Plans - CORRECT ANSWERS ✔✔Domain 1Drug plan customer service (3 measures) Domain 2 Member Complaints, Problems Getting Services, and improvement in the Drug Plan's Performance (4 measures) Domain 3 Member Experience with Drug Plan (2 measures) Domain 4 Patient afety and drug pricing (6measures) Star Rating penalize - CORRECT ANSWERS ✔✔when plans are not obtaining four stars or better
Major Reason for RA - CORRECT ANSWERS ✔✔To identify all current diagnoses to highest specificity. Annual RA Audits - CORRECT ANSWERS ✔✔CMS conducts audits of the risk adjustment data submitted by or on behalf of health plans to ensure program integrity Error in RA Audits - CORRECT ANSWERS ✔✔once error determine will then be applied to the premiums for the entire patient population for that health plan RADV(Risk Adustment Data Validation) - CORRECT ANSWERS ✔✔CMS identifies a random stratified sample of patients audit. Only Part C HCC'S are audited in a RADV RADV submission - CORRECT ANSWERS ✔✔must submit up to five best recrods demonstrating diagnoses as current in year being audited and support the HCC values Two types of RADV audit - CORRECT ANSWERS ✔✔National Radv audit and Targeted RADV National RADV audit - CORRECT ANSWERS ✔✔Selection of patients using a stratfied sample metholology, where a percentage of patients are selected randomly from high risk, medium risk, and low risk based on HCC risk scores Selection of MA plan and/or contracts is random
Targeted RADV audit - CORRECT ANSWERS ✔✔Targeted contract of those who have had problematic past audit findings plans with higher risk scores when compared to traditional FFS(Fee-For-Service Medicare) HHS RADV - CORRECT ANSWERS ✔✔identifes a similar sample of patients, however the dos only come from those that were submitted on claims through the edge servers IVA - CORRECT ANSWERS ✔✔Initial Validation Auditor that reviews the sample to identify DOS that support HCC'S(through diagnosis codes) IVA process - CORRECT ANSWERS ✔✔is typicall summer and fall months winter and fall months are SVA(Secondary Validation Auditor Differences between the CMS RADV AND HHS HRADV - CORRECT ANSWERS ✔✔cms RADV is typically 2-3 years after payment, while HHS HRADV is typically 6 months after year end Differences between the CMS RADV and HHS HRADV - CORRECT ANSWERS ✔✔CMS RADV allows for any face to face encounter by an approved provider to be subitted for audit support while HHC HRADV only allows DOS that were submitted on t he edge server.
Value of an Invalid HCC - CORRECT ANSWERS ✔✔extrapolated across the entire plan population ($350 x 1,500) code a proper vascular ulcer - CORRECT ANSWERS ✔✔must have the location and type Pancreatic islet - CORRECT ANSWERS ✔✔Produces Blood Sugar HEDIS 2 - CORRECT ANSWERS ✔✔Is not a division of Medicare and Medicaid Organ - CORRECT ANSWERS ✔✔Multiple tissue types formed together a specific function for the body Organ System - CORRECT ANSWERS ✔✔A collection of body parts depending on one another to achieve a mutual objective
