CRC EXAM QUESTIONS WITH
VERIFIED SOLUTIONS
Risk Adjustment Data Element - ANSWER-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 - ANSWER-Risk Adjustment Factor Scores
Three main types of reviews - ANSWER-Retrospective, Concurrent and prospective
Retrospective - ANSWER-reviews are performed after the information has been
reported and in risk adjustment these are prior years dos
Concurrent reviews - ANSWER-performed ongoing as patients are seen prior to
reporting and in risk adjustment the current year
Prospective reviews - ANSWER-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) - ANSWER-HHS hEALTH AND HUMAN
SERVICES hIERARCHICAL CONDITION(Commercial, individual and small grooup
Part D Plans - ANSWER-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 - ANSWER-when plans are not obtaining four stars or better
PQRS - ANSWER-Physician Quality Reporting System
PQRS 2 - ANSWER-A Reporting program using a combination of incentive payments
and payment adjustments to promote reporting of quality information by eligible
professionals (EP)
, Valued-Based Payment Modifier Program - ANSWER-Provide Performance information
to physicians as part of Medicare's efforts to improve the quality and efficiency of
medical care
HEDIS - ANSWER-The Healthcare Effectiveness Data and Information Set)
HEDIS 3 - ANSWER-Tract year to year performance
81 HEDIS Measures DIVIDED into five domains of care - ANSWER-1. Effectiveness of
Care
2. Access/Availability of Care
3. Experience of Care
4. Utilization and relative resource use
5. Health Plan Descriptive Information
Major Reason for RA - ANSWER-To identify all current diagnoses to highest specificity.
Annual RA Audits - ANSWER-CMS conducts audits of the risk adjustment data
submitted by or on behalf of health plans to ensure program integrity
Error in RA Audits - ANSWER-once error determine will then be applied to the
premiums for the entire patient population for that health plan
RADV(Risk Adustment Data Validation) - ANSWER-CMS identifies a random stratified
sample of patients audit. Only Part C HCC'S are audited in a RADV
RADV submission - ANSWER-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 - ANSWER-National Radv audit and Targeted RADV
National RADV audit - ANSWER-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 - ANSWER-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 - ANSWER-identifes a similar sample of patients, however the dos only
come from those that were submitted on claims through the edge servers
IVA - ANSWER-Initial Validation Auditor that reviews the sample to identify DOS that
support HCC'S(through diagnosis codes)
VERIFIED SOLUTIONS
Risk Adjustment Data Element - ANSWER-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 - ANSWER-Risk Adjustment Factor Scores
Three main types of reviews - ANSWER-Retrospective, Concurrent and prospective
Retrospective - ANSWER-reviews are performed after the information has been
reported and in risk adjustment these are prior years dos
Concurrent reviews - ANSWER-performed ongoing as patients are seen prior to
reporting and in risk adjustment the current year
Prospective reviews - ANSWER-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) - ANSWER-HHS hEALTH AND HUMAN
SERVICES hIERARCHICAL CONDITION(Commercial, individual and small grooup
Part D Plans - ANSWER-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 - ANSWER-when plans are not obtaining four stars or better
PQRS - ANSWER-Physician Quality Reporting System
PQRS 2 - ANSWER-A Reporting program using a combination of incentive payments
and payment adjustments to promote reporting of quality information by eligible
professionals (EP)
, Valued-Based Payment Modifier Program - ANSWER-Provide Performance information
to physicians as part of Medicare's efforts to improve the quality and efficiency of
medical care
HEDIS - ANSWER-The Healthcare Effectiveness Data and Information Set)
HEDIS 3 - ANSWER-Tract year to year performance
81 HEDIS Measures DIVIDED into five domains of care - ANSWER-1. Effectiveness of
Care
2. Access/Availability of Care
3. Experience of Care
4. Utilization and relative resource use
5. Health Plan Descriptive Information
Major Reason for RA - ANSWER-To identify all current diagnoses to highest specificity.
Annual RA Audits - ANSWER-CMS conducts audits of the risk adjustment data
submitted by or on behalf of health plans to ensure program integrity
Error in RA Audits - ANSWER-once error determine will then be applied to the
premiums for the entire patient population for that health plan
RADV(Risk Adustment Data Validation) - ANSWER-CMS identifies a random stratified
sample of patients audit. Only Part C HCC'S are audited in a RADV
RADV submission - ANSWER-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 - ANSWER-National Radv audit and Targeted RADV
National RADV audit - ANSWER-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 - ANSWER-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 - ANSWER-identifes a similar sample of patients, however the dos only
come from those that were submitted on claims through the edge servers
IVA - ANSWER-Initial Validation Auditor that reviews the sample to identify DOS that
support HCC'S(through diagnosis codes)
