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 'encounter data' in Medicare Advantage?
Answer: Claim-like records submitted by MA plans reporting all services rendered to enrollees
Encounter data are claim-like records that MA plans submit to CMS reporting all medical services provided to their enrollees.
The 'payment reconciliation' process in Medicare Advantage occurs because:
Answer: Initial risk scores are based on incomplete data and are updated as more diagnosis data becomes available
Initial risk scores are prospective estimates; CMS reconciles payments mid-year and at year-end when more complete encounter data is available.
Which entity is responsible for submitting encounter data to CMS on behalf of Medicare Advantage enrollees?
Answer: Medicare Advantage Organizations (MAOs)
Medicare Advantage Organizations are responsible for collecting and submitting encounter data to CMS for all services rendered to their enrollees.
What is the 'minimum data set' (MDS) used for in Medicare Advantage risk adjustment?
Answer: Assessing functional and health status of nursing facility residents to apply the frailty adjuster
The MDS is a comprehensive assessment tool for nursing facility residents that CMS uses to determine frailty adjuster eligibility in MA risk adjustment.
What does CMS use to compare MA plan costs to expected costs under traditional Medicare?
Answer: The bid-to-benchmark ratio
CMS compares each MA plan's bid to the county benchmark to determine whether the plan receives a rebate or charges a premium to enrollees.
Which of the following BEST describes the purpose of the CMS-HCC risk adjustment model?
Answer: To prospectively predict expected healthcare costs based on prior-year diagnoses and demographics
The CMS-HCC model prospectively predicts expected healthcare costs for each MA enrollee based on their prior-year diagnoses and demographic characteristics.