Quality Assurance & Standards Flashcards
7 cards from real CMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Assurance & Standards flashcards as text
Which CMS audit type specifically evaluates a Medicare Advantage organization's administration of the Part D benefit, including formulary compliance?
Answer: Program Audit
CMS Program Audits assess MA-PD plan compliance across multiple areas including Part D administration, formulary management, and appeals/grievances processes.
What does the CMS 'Triple Aim' framework seek to simultaneously achieve?
Answer: Improve patient experience, improve population health, and reduce per capita costs
The Triple Aim, developed by the Institute for Healthcare Improvement and adopted by CMS, focuses on improving patient experience, improving population health, and reducing per capita healthcare costs.
Under CMS standards, how often must Medicare Advantage plans update their Quality Improvement Program (QIP) evaluations?
Answer: Annually
MA plans must conduct and submit annual evaluations of their Quality Improvement Programs to CMS, demonstrating ongoing performance monitoring and improvement efforts.
The Nursing Home Compare Five-Star Quality Rating System evaluates nursing facilities on which three domains?
Answer: Health inspections, staffing, and quality measures
Nursing Home Compare rates facilities across three domains: health inspections (state surveys), staffing levels and turnover, and quality measures derived from resident assessment data.
A Medicare Advantage organization discovers an overpayment due to a risk adjustment error. Under CMS rules, what must the plan do?
Answer: Report and return the overpayment within 60 days of identification
Under the 60-day rule, MA organizations must report and return identified overpayments to CMS within 60 days of the date the overpayment is identified.
Which CMS-required standard ensures Medicare Advantage plans maintain a sufficient number and mix of providers for enrollees to access covered services?
Answer: Network Adequacy Standards
Network Adequacy Standards require MA plans to maintain provider networks with sufficient numbers, types, and geographic distribution to provide enrollees timely access to covered services.
Under CMS quality standards, what is the primary goal of a Medicare Advantage plan's Utilization Management (UM) program?
Answer: To ensure appropriate and medically necessary care is provided efficiently while protecting enrollees
UM programs must be designed to ensure enrollees receive medically necessary, appropriate care efficiently without creating barriers to needed services, per CMS regulations.