CDEO Chapter 8 All Possible Questions and Answers with complete solution

Quality Bonus Payments - TO make quality of care a priority the Affordable Care Act set a requirement that CMS make quality bonus payments to Medicare Advantage plans that earn four or more stars in a five-star quality rating system would receive a bonus payment. Earning fewer than four stars would receive no bonus. Suspect Logic - Many organizations utilize a method such as this one to uncover diagnoses which are likely present but unreported or unknown Chart Reviews - Analysis of the information identified is used to target retrospective reviews to capture any unreported diagnoses Suspect Logic Factors - * Known/Expected clinical progression of an illness or disease * DME needs * PDE * Laboratory test findings * CPT codes reported during the year in review * HCPCS codes reported during the year in review * Socioeconomic status * Disability: Hospice: ESRD and other such statuses of the patient being reviewed Quality of Care - Quality Measures Star Ratings HEDIS - Healthcare Effectiveness Data and Information Set CMS Stars Ratings -QBPs - Quality Bonus Payments CMS Demonstration Period - Beginning in 2012, CMS conducted a nationwide 3 year demonstration project where by a scaled bonus program was used, with the expectation that Medicare Advantage organizations with three or more stars would push themselves toward earning four and five star ratings. During this period, plans that were at or above three stars would receive quality bonus payments based on a sliding scale. PREDICTIVE MODELING - is an analytical review of known data elements to establish a hypothesis related to the future health needs of patients or a population of patients Star Ratings - the star ratings ranked plans on a calse from one to five stars, in half-star increments defined in the following manner * 5 STARS = EXCELLENT PERFORMANCE * 4 STARS = ABOVE AVERAGE PERFORMANCE * 3 STARS = AVERAGE PERFORMANCE * 2 STARS = BELOW AVERAGE PERFORMANCE * 1 STAR = POOR PERFORMANCE Stars Ratings - are based on individual quality metrics or measures, variable weights are given to each measure; those related to outcomes are weighted highest, followed by patient experience measures and process measures. Medicare Advantage Plans as well as Prescription Drug Plans, are equally tasked with these quality measures. Medicare Advantage HMO Plan Part C: Domain 1 - Domain 1: Staying Healthy- Screenings, Test, and Vaccines (7 Measures) Breast Cancer Screening Colorectal Cancer ScreeeningAnnual Flu Vaccine Improving or Maintaining Physical Health Improving or Maintaining Mental Health Monitoring Physical Activity Adult BMI Assessment Medicare Advantage HMO Plan Part C: Domain 2 - Domain 2: Managing Chronic Conditions (12 Measures) -SNP Care Management -Care for Older Adults - Medication Review -Care for Older Adults - Functional Status ---Assessment -Care for Older Adults - Pain Screening -OMW -CDC-EE -CDC- Kidney Disease Monitoring -CDC- Blood Sugar Control -CDC- Cholesterol Controlled -CBP -RA Management -Reducing the Risk of Falling -Improving Bladder Control -MRP -Plan All-Cause Readmissions Medicare Advantage HMO Plan Part C: Domain 3 - Domain 3: Member Experience with Health Plan (6 Measures) -Getting Needed Care-Getting Appointments and Care Quickly -Customer Service -Rating of Health Care Quality -Rating of Health Plan -Care Coordination Medicare Advantage HMO Plan Part D: Domain 1 - Domain 1: Drug Plan Customer Services (3 measures) -Call Center - Foreign Language Interpreter and TTY Availability -Appeals Auto-Forward -Appeals Upheld Medicare Advantage HMO Plan Part D: Domain 2 - Domain 2: Member Complaints and Changes in the Drug Plan's Performance (4 Measures) -Complaints About the Drug Plan -Members Choosing to Leave the Plan -Beneficiary Access and Performance Problems -Drug Plan Quality Improvement