Medicare Advantage Payment Methodology Flashcards
6 cards from real CRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medicare Advantage Payment Methodology flashcards as text
What is 'upcoding' in the context of Medicare Advantage?
Answer: Reporting higher-severity diagnoses than documented to inflate risk scores
Upcoding refers to reporting diagnoses of greater severity than supported by documentation to artificially inflate risk scores and payments.
The benchmark in Medicare Advantage is based on:
Answer: County-level fee-for-service Medicare spending rates
MA benchmarks are set at the county level based on projected fee-for-service Medicare spending in that county.
What is a 'quality bonus payment' in Medicare Advantage?
Answer: Additional payment for plans with 4 or more stars on the CMS Star Rating
MA plans with 4 or more stars on the CMS Star Rating system receive quality bonus payments as a percentage increase to their benchmark.
Which of the following is used when no prior-year diagnosis data exists for a newly enrolled MA member?
Answer: New enrollee model using only demographic factors
The new enrollee model uses only demographic factors such as age, sex, and Medicaid status since no prior-year diagnosis data exists for newly enrolled members.
What does 'risk score trending' mean in Medicare Advantage?
Answer: Monitoring year-over-year changes in risk scores to identify documentation patterns
Risk score trending monitors year-over-year changes to identify patterns indicating potential upcoding or documentation improvement opportunities.
Which of the following conditions would MOST likely increase a patient's risk score significantly?
Answer: Stage 4 chronic kidney disease with diabetes
Stage 4 CKD with diabetes represents multiple high-cost HCCs that significantly increase a patient's predicted cost and risk score.