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CRC FINAL EXAM NEWEST 2025 ACTUAL EXAM COMPLETE 250 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED CORRECT ANSWER) ALREADY GRADED A+.
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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?
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
management programs In the CMS Star Ratings program, which measure is given the highest weight?
d. Accurate RAF scores - CORRECT ANSWER:->a. Outcomes How often are HEDIS measures revised?a. As needed
Which statement is TRUE regarding the CMS Stars qualityrating system?
score at least four stars.
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?
related to the future health of clients.
cost of future healthcare.
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:
comorbidities due to a lack of care.
diagnoses for an individual client.
provided.
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?
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?
certification by HHS.
logic from reimbursement.
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?
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?
the health care exchange.
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
Disability Payment System CDPS is the RA model used by Medicaid What is the purpose of the coding intensity adjustment?
covered by Part A.
covered by Part B.
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>
High
d. Very high - CORRECT ANSWER:->b. Medium Which elements are considered the Medicare HCC model?a. age
Which statement is TRUE regarding the Coding IntensityAdjustment?
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.
normalization adjustment.
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?
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
d. MIPS What is the lowest star rating a plan must achieve to void penalties?
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