CRC Exam 3 with all Correct & 100% Verified Answers |
Already Graded A+
5 charts ✔Correct Answer-How many charts can be submitted to CMS to validate an HCC?
Financial penalties will be imposed across the plan membership ✔Correct Answer-As of 2014, the
results of a RADV audit will be "extrapolated" across all members of the plan that was audited. What
does this mean?
Retrospective audits generally include finding additional diagnoses, CMS has stated that the deletion
of conditions needs to be part of these audits; why is it so hard for companies to follow CMS
directives? ✔Correct Answer-These audits can mandate that insurance companies repay CMS for
past revenues which will decrease the bottom line for the stock holders. Billing compliance issues
might come into play and a deeper dive might be warranted for specific provider offices which will
cause abrasion with the providers.
Which statement(s) is/are TRUE regarding retrospective audits? ✔Correct Answer-Both internal
and external, onshore and offshore resources can perform retrospective chart audits as long as a
Business Agreement is signed by the external vendor. Retrospective audits are performed following
data submission to validate correct information was submitted and correct any errors in data
submitted.
problem list ✔Correct Answer-I. In some EHRs the problem list can be carried over from a previous
visit without updating the information
II. Problem lists include chronic conditions
III. Problem lists can include previously treated conditions.
IV. In some EHRs the problem list can include conditions from previous years
5 star rating ✔Correct Answer-CMS defines the star ratings 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
What does the abbreviation RADV indicate? ✔Correct Answer-RADV indicates Risk Adjustment
Data Validation
Rule out diagnosis ✔Correct Answer-A rule out diagnosis cannot be reported for outpatient
services. The provider documents the rule out diagnoses in the patient chart to capture the medical
decision making but a diagnosis code is not reported.
HCC categorization ✔Correct Answer-The model takes ICD codes and filters them into Diagnosis
Groups (DxGs), then into Condition Categories (CCs), where hierarchies or "families" of conditions
are placed to gain an HCC numeric code, which translates to a risk adjustment factor (RAF) value.
Excluded provider ✔Correct Answer-Medicare will not pay for items or services rendered to
beneficiaries and recipients by an excluded provider or by entities owned or managed by an excluded
provider. Therefore, MA organizations should not submit risk adjustment data if it was submitted by
Already Graded A+
5 charts ✔Correct Answer-How many charts can be submitted to CMS to validate an HCC?
Financial penalties will be imposed across the plan membership ✔Correct Answer-As of 2014, the
results of a RADV audit will be "extrapolated" across all members of the plan that was audited. What
does this mean?
Retrospective audits generally include finding additional diagnoses, CMS has stated that the deletion
of conditions needs to be part of these audits; why is it so hard for companies to follow CMS
directives? ✔Correct Answer-These audits can mandate that insurance companies repay CMS for
past revenues which will decrease the bottom line for the stock holders. Billing compliance issues
might come into play and a deeper dive might be warranted for specific provider offices which will
cause abrasion with the providers.
Which statement(s) is/are TRUE regarding retrospective audits? ✔Correct Answer-Both internal
and external, onshore and offshore resources can perform retrospective chart audits as long as a
Business Agreement is signed by the external vendor. Retrospective audits are performed following
data submission to validate correct information was submitted and correct any errors in data
submitted.
problem list ✔Correct Answer-I. In some EHRs the problem list can be carried over from a previous
visit without updating the information
II. Problem lists include chronic conditions
III. Problem lists can include previously treated conditions.
IV. In some EHRs the problem list can include conditions from previous years
5 star rating ✔Correct Answer-CMS defines the star ratings 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
What does the abbreviation RADV indicate? ✔Correct Answer-RADV indicates Risk Adjustment
Data Validation
Rule out diagnosis ✔Correct Answer-A rule out diagnosis cannot be reported for outpatient
services. The provider documents the rule out diagnoses in the patient chart to capture the medical
decision making but a diagnosis code is not reported.
HCC categorization ✔Correct Answer-The model takes ICD codes and filters them into Diagnosis
Groups (DxGs), then into Condition Categories (CCs), where hierarchies or "families" of conditions
are placed to gain an HCC numeric code, which translates to a risk adjustment factor (RAF) value.
Excluded provider ✔Correct Answer-Medicare will not pay for items or services rendered to
beneficiaries and recipients by an excluded provider or by entities owned or managed by an excluded
provider. Therefore, MA organizations should not submit risk adjustment data if it was submitted by
