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CRC FINAL EXAM NEWEST 202 5 ACTUAL EXAM
COMPLETE 250 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED CORRECT ANSWER)
ALREADY GRADED A+.
How is predictive modeling used in risk adjustment? - CORRECT ANSWER :->to determine suspected diagnosis based on data elements. Which of the following data elements are used in predictive modeling?
I. DME claims
II. Prescription drug eventsIII.
Physician claims data IV. Facility claims data a. III and IV b. I, II, and IVc. I, II, and III d. I, II, III, and IV - CORRECT ANSWER :->d. I, II, III, and IV What might happen as a result of predictive modeling? a. Disease management programs
b. Concurrent audits
c. Transporation benefits
d. Reduction in case management - CORRECT ANSWER:-> a.Disease
management programs In the CMS Star Ratings program, which measure is given the highest weight?
a. Outcomes
b. Client experience
c. Customer service
d. Accurate RAF scores - CORRECT ANSWER:->a. Outcomes How often are HEDIS measures revised?a. As needed
b. Monthly
c. Bi-annually
d. Annually - CORRECT ANSWER:->d. Annually
Which statement is TRUE regarding the CMS Stars qualityrating system?
a. Quality bonus payments are made to physician who scoreat least four stars.
b. Quality bonus payments are made to Medicare Advantage plans who
score at least four stars.
c. Quality bonus payments are made to physician who scoreat least five stars.
d. Quality bonus payments are made to Medicare Advantage plans who score at
V. Health Plan Customer Service
a. I, II and III b. I, III, and V c. I, II, III, IV and V d. I, II, III and V - CORRECT ANSWER:->c. I, II, III, IV and V What are the participation tracks available through MedicareAccess and CHIP Reauthorization Act (MACRA)? I. Merit-based Incentive Payment SystemsII. Sustainable Growth System III. Advanced Alternative Payment Models a. I b. II and III c. I and III d. I, II and III - CORRECT ANSWER:->c. I and III What is predictive modeling?
a. An analytical review of known data elements to establish a hypothesis
related to the future health of clients.
b. An analytical review of payments to health plans todetermine the
cost of future healthcare.
c. An average of costs associated with diagnoses used to determine which
providers to contract with for a health plan. d. An average payment associated with diagnoses used to determine which health plans providers should contract with. - CORRECT ANSWER:->a. An analytical review of known data elements to establish a hypothesis related to the future healthof clients. Who developed and maintains HEDIS?a. CMS b. OIG c. BCBS d. NCQA - CORRECT ANSWER:->d. NCQA What do the Star Ratings identify? a. Top performing health plans based on qualityb. Top performing doctors based on quality c. Cost of healthcare in facilities d. Cost of healthcare by provider - CORRECT ANSWER:->a. Top performing health plans based on quality What is the goal of HEDIS? a. Allow for clients to rate their physicians.b. Allow clients to compare health plans. c. Allow clients to schedule appointments online.
a. Diabetes mellitusb. Asthma c. Osteoporosis d. Hypertension - CORRECT ANSWER:->b. Asthma If you were using a predictive model and the results were:
- The member had a DME claim for a cane.
- The member had an Rx Claim for a Fosamax.
- The member had a medical claim for a bone density scan.Which diagnosis would you predict this member has?a. Osteoarthritis b. Degenerative joint disease of the kneec. Spinal Stenosis d. Osteoporosis - CORRECT ANSWER:->d. Osteoporosis Which statement is TRUE regarding predictive modeling?
a. Predictive models are only used to identify clients whodevelop
comorbidities due to a lack of care.
b. Health plans often use predictive modeling to anticipate potential future
diagnoses for an individual client.
c. Predictive modeling identifies needs a client had in thepast that was not
provided.
d. Providers can use predictive modeling to identify when additional staff is
required. - CORRECT ANSWER:->b. Health plansoften use predictive modeling to anticipate potential future diagnoses for an individual client. How is HEDIS data collected?I. Surveys II. Medical chart reviewsIII. Insurance claims All of the above - CORRECT ANSWER:->all of the above Predictive modeling can use many data elements. Which are beneficial for identifying a person with diabetes?
I. Rx claims
II. Medical claimsIII.
DME claims
b. CMS website.c. OCR website. d. QPP website. - CORRECT ANSWER:->b. CMS website. Which of the following is TRUE regarding the risk adjustment model by HHS?
a. States are mandated to use the Medicare HCCs.
b. States can either use the federal methodology or proposean alternate for
certification by HHS.
c. States can either use the federal methodology or exclude risk adjustment
logic from reimbursement.
d. States can determine their own policy for payment without a risk adjustment
component. - CORRECT ANSWER:->b. States can either use the federal methodology or propose an alternate forcertification by HHS. When reporting a code for retinopathy, must the coder find documentation from an ophthalmologist in order to code thecondition as an active condition?
a. yes, speciality specific diagnosis can only be reported by aspecialist.
b. yes, ophthalmologist must diagnosis all eye relatedconditions.
c. No, any approved provider can validate any diagnosis. d. No only PCP
can provide supporting documentation forreported diagnoses. - CORRECT ANSWER:->c. No, any approvedprovider can validate any diagnosis. Under the Affordable Care Act(ACA), can health plans change the premium rate based on a client's health status where clients with more complex medical issues are required to pay a higher premium than clients with less complex medical issues?
a. Yes, as long as the more complex medical conditions are documented.
b. Yes, as long as the client discloses the information whenenrolling in a plan on
the health care exchange.
c. No, health plans can not charge different premiums based on health status.
d. No, health plans are prohibited from participating in the ACA risk
adjustment model. - CORRECT ANSWER:->c. No, healthplans can not charge different premiums based on health status. How often is the normalization factor adjusted?a. monthly b. twice per yearc. yearly
d. demographic variances e. exceptions - CORRECT ANSWER:->a. interactions Interactions are extra risk adjustment values or factors added when a client has more than one major significant diagnosis identified in the model. These interactions add value because it is understood that having a combination of some diagnosestogether increase clinical risk and associated costs of care. Each year, Medicare normalizes risk scores to maintain anaverage of what? - CORRECT ANSWER:->1. What does the abbreviation CDPS indicate?a. Chronic Disability Provider Services
b. Chronic Diagnosis Processing System
c. Chronic Disability Payment System
d. Chronic Disability Payment System - CORRECT ANSWER:->c.Chronic
Disability Payment System CDPS is the RA model used by Medicaid What is the purpose of the coding intensity adjustment?
I. Determine different coding patterns in HCC compared to inclient claims
covered by Part A.
II. Determine different coding patterns in HCC compared to outclient claims
covered by Part B.
III. Determine different coding patterns in HCC compared toclaims processed
under CDPS. a. I b. II c. I and II d. I, II, & III - CORRECT ANSWER:->c. I and II CMS is required to make an adjustment to reflect "differences in coding patterns between Medicare Advantage plans and providers under Pay A and B to the extent that the Secretary has identified such differences. Under the Health and Human Services (HHS) Hierarchial Condition Category model, which of the below plans has the highest out of pock expense once the premium is paid? a. Silver b. Gold c. Bronze d. Platinum - CORRECT ANSWER:->c. Bronze
Which provider is NOT an approved provider for diagnosis code capture under the Medicare HCC model? a. Gynecologist.b. Pathologist. c. Oral surgeon. d. Registered Caregiver. - CORRECT ANSWER:->d. Registered Caregiver. In the CDPS risk adjustment model, what category do heartattacks fall under>
a. Low
b. Mediumc.
High
d. Very high - CORRECT ANSWER:->b. Medium Which elements are considered the Medicare HCC model?a. age
b. disability status
c. conditions that affect the long-term treatment of the clientinsurance status.
d. All of the above - CORRECT ANSWER:->d. all of the above
Which statement is TRUE regarding the Coding IntensityAdjustment?
a. MA plan risk scores and FFS scores typical decrease.
b. FFS scores and MA plan risk scores increase at the same rate.
c. FFS scores increase faster than MA plan risk scores. d. MA plan risk
scores increase faster than FFS scores. - CORRECT ANSWER:->d. MA plan risk scores increase faster thanFFS scores. CMS is required to make an adjustment to reflect "differences in coding patterns between Medicare Advantage plans and providers under Pay A and B to the extent that the Secretary has identified such differences. To do this, CMS conducts extensive research to analyze changes inMA and original fee-for-service (FFS) Medicare risk scores, differences between those changes, and coding patterns behind these changes. CMS uses the results of this analysis to develop a factor thatis applied to the risk score to account for these differences.
plan.
c. The average FFS expenses and rates are used todetermine the FFS
normalization adjustment.
d. The average FFS expenses and rates are used to determine the maximum
payment per RAF score. - CORRECT ANSWER:->>>
c. The average FFS expenses and rates are used to determine the FFS normalization adjustment. Under the Health and Human Services (HHS) Hierarchal Condition Category (HCC) model, which plan has the lowestout of pocket expense once the premium is paid? a. Silver b. Gold c. Bronze d. Platinum - CORRECT ANSWER:->d. Platinum What is the step after predictive modeling identifies a diagnosis gap?
a. Perform a retrospective audit to confirm proper diagnosiscode selection.
b. Develop a process to capture more accurate diagnosis going forward.
c. Change the diagnosis if it results in higher risk adjustment. d. Change the
diagnosis regardless of the risk adjustment. - CORRECT ANSWER:->a. Perform
a retrospective audit to confirm proper diagnosis code selection. Which of the following is a quality review measure?a. APC
b. DRG
c. Uniform Hospital Discharge Data Set (UHDDS)
d. Merit-based Incentive Payment System (MIPS) - CORRECT ANSWER:->>>
d. MIPS What is the lowest star rating a plan must achieve to void penalties?
a. 5
b. 4
c. 3
d. 2 - CORRECT ANSWER:->b. 4
When is added value factored into the RAF for the HCC model for disease interaction? a. When two or more chronic conditions are reported b. When there is an exacerbation of a chronic illness c. When two chronic illnesses paired together are complex to treat
