RISK ADJUSTMENT MODELS
1. Helps forecast anticipated health costs 2. Adjusts payments based on diagnoses & 3.
Helps identify patients w/higher medical needs - Answers- HCC RA Model does what 3
things
2106 - Answers- What year is the 2014 CMS_HCC risk model utilized fully with no
blending
25% & 75% - Answers- For PY2014 risk scores from 2013 modes were weighted @
___% and scores from 2014 were weighted @ ___%
67% & 33% - Answers- For PY2015 risk scores from 2013 were weighed at __% and
scores from 2014 were weighted at __%.
Adjust health plan revenue to better reflect the projected costs of population and
compensate plan that enroll high-cost pts - Answers- From a payment perspective, RA
models do what?
Bronze - Answers- plan that has the lowers premiums, and the highest deductibles/out
of pocket costs
Catastrophic - Answers- plans that have lower monthly premiums and high deductibles
and are used to protect pt from worst-case scenarios (life-threatening illness/injury);
however, most routine medical expenses aren't covered by these plans
Chronic Illness and Disability Payment System (CDPS) - Answers- Medicaid model that
has more diagnosis codes than HCC model; rated as very high, medium, low and extra
low risk; uses a hierarchal value system
Concurrent Review - Answers- performed ongoing, as patients are seen and may be
after or prior to reporting to CMS; typically the current year, combined with the prior
year's DOS
Current Diagnoses, Known Status Codes & Family History Codes - Answers- The
common goal of CDPS model is to capture the following:
Decrease - Answers- An increase in coding intensity factor causes ____ in the risk
scores
Deficit Reduction Act - Answers- legislation that requires CMS to apply the FFS
normalization factor to the risk score
1. Helps forecast anticipated health costs 2. Adjusts payments based on diagnoses & 3.
Helps identify patients w/higher medical needs - Answers- HCC RA Model does what 3
things
2106 - Answers- What year is the 2014 CMS_HCC risk model utilized fully with no
blending
25% & 75% - Answers- For PY2014 risk scores from 2013 modes were weighted @
___% and scores from 2014 were weighted @ ___%
67% & 33% - Answers- For PY2015 risk scores from 2013 were weighed at __% and
scores from 2014 were weighted at __%.
Adjust health plan revenue to better reflect the projected costs of population and
compensate plan that enroll high-cost pts - Answers- From a payment perspective, RA
models do what?
Bronze - Answers- plan that has the lowers premiums, and the highest deductibles/out
of pocket costs
Catastrophic - Answers- plans that have lower monthly premiums and high deductibles
and are used to protect pt from worst-case scenarios (life-threatening illness/injury);
however, most routine medical expenses aren't covered by these plans
Chronic Illness and Disability Payment System (CDPS) - Answers- Medicaid model that
has more diagnosis codes than HCC model; rated as very high, medium, low and extra
low risk; uses a hierarchal value system
Concurrent Review - Answers- performed ongoing, as patients are seen and may be
after or prior to reporting to CMS; typically the current year, combined with the prior
year's DOS
Current Diagnoses, Known Status Codes & Family History Codes - Answers- The
common goal of CDPS model is to capture the following:
Decrease - Answers- An increase in coding intensity factor causes ____ in the risk
scores
Deficit Reduction Act - Answers- legislation that requires CMS to apply the FFS
normalization factor to the risk score
