CDEO Chapter 8 UPDATED ACTUAL
Exam Questions and CORRECT Answers
PREDICTIVE MODELING - CORRECT ANSWER - 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
Suspect Logic - CORRECT ANSWER - Many organizations utilize a method such as this one
to uncover diagnoses which are likely present but unreported or unknown
Chart Reviews - CORRECT ANSWER - Analysis of the information identified is used to
target retrospective reviews to capture any unreported diagnoses
Suspect Logic Factors - CORRECT ANSWER - * 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 - CORRECT ANSWER - Quality Measures
Star Ratings
HEDIS - CORRECT ANSWER - Healthcare Effectiveness Data and Information Set
CMS Stars Ratings - CORRECT ANSWER -
, QBPs - CORRECT ANSWER - Quality Bonus Payments
Quality Bonus Payments - CORRECT ANSWER - 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.
CMS Demonstration Period - CORRECT ANSWER - 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.
Star Ratings - CORRECT ANSWER - 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 - CORRECT ANSWER - 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 - CORRECT ANSWER - Domain 1:
Staying Healthy- Screenings, Test, and Vaccines (7 Measures)
Exam Questions and CORRECT Answers
PREDICTIVE MODELING - CORRECT ANSWER - 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
Suspect Logic - CORRECT ANSWER - Many organizations utilize a method such as this one
to uncover diagnoses which are likely present but unreported or unknown
Chart Reviews - CORRECT ANSWER - Analysis of the information identified is used to
target retrospective reviews to capture any unreported diagnoses
Suspect Logic Factors - CORRECT ANSWER - * 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 - CORRECT ANSWER - Quality Measures
Star Ratings
HEDIS - CORRECT ANSWER - Healthcare Effectiveness Data and Information Set
CMS Stars Ratings - CORRECT ANSWER -
, QBPs - CORRECT ANSWER - Quality Bonus Payments
Quality Bonus Payments - CORRECT ANSWER - 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.
CMS Demonstration Period - CORRECT ANSWER - 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.
Star Ratings - CORRECT ANSWER - 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 - CORRECT ANSWER - 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 - CORRECT ANSWER - Domain 1:
Staying Healthy- Screenings, Test, and Vaccines (7 Measures)
