Prospective and Retrospective Risk Adjustment Strategies Flashcards
7 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 7 Prospective and Retrospective Risk Adjustment Strategies flashcards as text
Which risk adjustment strategy involves reviewing medical records AFTER the date of service to identify and submit diagnoses that support HCC capture?
Answer: Retrospective coding
Retrospective coding involves reviewing medical records after services have been rendered to identify diagnoses and submit them to improve risk score accuracy.
A health plan conducts annual wellness visits with structured questionnaires to ensure chronic conditions are captured before the coding year ends. This is an example of which strategy?
Answer: Prospective risk adjustment
Prospective risk adjustment involves activities conducted during or before the date of service to ensure conditions are documented and coded in the current benefit year.
What is the primary goal of a 'chase program' in risk adjustment?
Answer: To identify members with suspected undocumented conditions and prompt provider outreach
A chase program identifies members who likely have chronic conditions based on claims or pharmacy data but lack supporting face-to-face documentation, then prompts provider outreach to close those gaps.
Supplemental data sources used in retrospective risk adjustment most commonly include which of the following?
Answer: Medical records, lab data, and pharmacy data reviewed outside the normal claims flow
Supplemental data sources include medical records, lab results, and pharmacy data that are reviewed outside the traditional encounter data submission flow to capture additional diagnoses.
Under Medicare Advantage risk adjustment, what is the diagnosis submission deadline for the prior benefit year under the retrospective data submission timeline?
Answer: March 31 of the current year
CMS requires that diagnoses from the prior benefit year be submitted via encounter data by March 31 of the current payment year for inclusion in the final risk score reconciliation.
Which of the following best describes a 'gap closure' activity in prospective risk adjustment?
Answer: Scheduling patients with chronic conditions for annual visits to document and code existing diagnoses
Gap closure in prospective risk adjustment refers to scheduling members with chronic conditions for visits so that providers can document and code those conditions before the benefit year closes.
A health plan uses pharmacy claims showing prescriptions for insulin and metformin to identify members who may have undocumented diabetes. This is an example of using supplemental data for which purpose?
Answer: Prospective member targeting for outreach
Using pharmacy data to identify members with probable chronic conditions not documented in encounters is a common prospective targeting method to prioritize outreach and close coding gaps.