CMS Quality Assurance & Standards 3 — Questions and Answers
Question 1: What does the Hospital Readmissions Reduction Program (HRRP) penalize hospitals for?
- High infection rates
- Excessive readmissions within 30 days for certain conditions (Correct answer)
- Low patient satisfaction scores
- Failure to use electronic health records
Correct answer: Excessive readmissions within 30 days for certain conditions
The HRRP reduces Medicare payments to hospitals with higher-than-expected 30-day readmission rates for conditions such as heart attack, heart failure, and pneumonia.
Question 2: Which CMS quality framework uses the domains of Safe, Timely, Effective, Efficient, Equitable, and Patient-centered?
- Triple Aim
- STEEEP framework
- Quadruple Aim
- IOM Six Aims (Correct answer)
Correct answer: IOM Six Aims
The Institute of Medicine (IOM) identified six aims for quality improvement—Safe, Timely, Effective, Efficient, Equitable, and Patient-centered—in 'Crossing the Quality Chasm.'
Question 3: Under CMS regulations, Medicare Advantage organizations must have a Quality Improvement Program that includes which required element?
- Annual actuarial review
- Chronic care improvement programs (CCIPs) (Correct answer)
- Pharmacy benefit management audits
- Annual marketing material review
Correct answer: Chronic care improvement programs (CCIPs)
MA organizations are required to operate Chronic Care Improvement Programs (CCIPs) targeting enrollees with multiple chronic conditions as part of their Quality Improvement Program.
Question 4: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey measures which aspect of Medicare plan quality?
- Clinical outcomes
- Financial solvency
- Member experience and satisfaction (Correct answer)
- Provider credentialing standards
Correct answer: Member experience and satisfaction
CAHPS surveys capture enrollee-reported experiences with their health plan and providers, contributing to star ratings under the Five-Star system.
Question 5: A Medicare Advantage plan is flagged as a 'low-performing plan.' What must CMS do under this designation?
- Immediately terminate the plan's contract
- Display a low-performing icon on Medicare Plan Finder (Correct answer)
- Restrict the plan to existing enrollees only
- Require the plan to reduce premiums
Correct answer: Display a low-performing icon on Medicare Plan Finder
CMS must display a low-performing plan icon on Medicare Plan Finder for plans rated below 2.5 stars for three consecutive years to alert beneficiaries.
Question 6: Which reporting mechanism do Medicare Advantage plans use to submit encounter data to CMS for risk adjustment and quality purposes?
- OASIS
- RAPS and EDPS (Correct answer)
- UB-04 only
- Medicare Summary Notice
Correct answer: RAPS and EDPS
MA plans submit encounter data through RAPS (Risk Adjustment Processing System) and EDPS (Encounter Data Processing System) for risk adjustment and quality oversight.
Question 7: Under the CMS Conditions of Participation, which entity has primary authority to investigate quality-of-care complaints in Medicare-certified facilities?
- State Survey Agencies (Correct answer)
- Medicare Administrative Contractors
- Quality Improvement Organizations
- The Office of Inspector General
Correct answer: State Survey Agencies
State Survey Agencies conduct inspections and investigate complaints at Medicare-certified facilities on behalf of CMS under the Conditions of Participation.
CMS Quality Assurance & Standards 3
What does the Hospital Readmissions Reduction Program (HRRP) penalize hospitals for?