CMS Quality Assurance & Standards 5

Question 1

Which CMS audit type specifically evaluates a Medicare Advantage organization's administration of the Part D benefit, including formulary compliance?

Accepted Answer

Program Audit

Answer

CMS Program Audits assess MA-PD plan compliance across multiple areas including Part D administration, formulary management, and appeals/grievances processes.

Question 2

What does the CMS 'Triple Aim' framework seek to simultaneously achieve?

Accepted Answer

Improve patient experience, improve population health, and reduce per capita costs

Answer

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.

Question 3

Under CMS standards, how often must Medicare Advantage plans update their Quality Improvement Program (QIP) evaluations?

Accepted Answer

Annually

Answer

MA plans must conduct and submit annual evaluations of their Quality Improvement Programs to CMS, demonstrating ongoing performance monitoring and improvement efforts.

Question 4

The Nursing Home Compare Five-Star Quality Rating System evaluates nursing facilities on which three domains?

Accepted Answer

Health inspections, staffing, and quality measures

Answer

Nursing Home Compare rates facilities across three domains: health inspections (state surveys), staffing levels and turnover, and quality measures derived from resident assessment data.

Question 5

A Medicare Advantage organization discovers an overpayment due to a risk adjustment error. Under CMS rules, what must the plan do?

Accepted Answer

Report and return the overpayment within 60 days of identification

Answer

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.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Quality Assurance & Standards 5