CDEO Chapter 8 Questions & Answers (Graded A)

Suspect Logic - ANSWER-Many organizations utilize a method such as this one to uncover diagnoses which are likely present but unreported or unknown Chart Reviews - ANSWER-Analysis of the information identified is used to target retrospective reviews to capture any unreported diagnoses Suspect Logic Factors - 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 - ANSWER-Quality Measures Star Ratings HEDIS - ANSWER-Healthcare Effectiveness Data and Information Set CMS Stars Ratings - ANSWER- QBPs - ANSWER-Quality Bonus Payments Quality Bonus Payments - 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 - 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