CRC Medicare Advantage Payment Methodology 2 — Questions and Answers
Question 1: What is 'upcoding' in the context of Medicare Advantage?
- The process of updating ICD-10-CM codes annually
- Reporting higher-severity diagnoses than documented to inflate risk scores (Correct answer)
- Adding supplemental codes to claims
- Converting ICD-9 codes to ICD-10 codes
Correct 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.
Question 2: The benchmark in Medicare Advantage is based on:
- The plan's historical costs
- County-level fee-for-service Medicare spending rates (Correct answer)
- National average Medicare costs
- State Medicaid rates
Correct 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.
Question 3: What is a 'quality bonus payment' in Medicare Advantage?
- Additional payment for plans with 4 or more stars on the CMS Star Rating (Correct answer)
- Payment for preventive care services
- Reimbursement for quality improvement initiatives
- Extra payment for high-risk patients
Correct 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.
Question 4: Which of the following is used when no prior-year diagnosis data exists for a newly enrolled MA member?
- Disease hierarchy model
- Standard demographic factor only
- New enrollee model using only demographic factors (Correct answer)
- ESRD adjustment
Correct 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.
Question 5: What does 'risk score trending' mean in Medicare Advantage?
- Tracking patient health outcomes over time
- Monitoring year-over-year changes in risk scores to identify documentation patterns (Correct answer)
- Predicting future disease states
- Comparing risk scores across different plans
Correct 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.
Question 6: Which of the following conditions would MOST likely increase a patient's risk score significantly?
- Seasonal allergies
- Stage 4 chronic kidney disease with diabetes (Correct answer)
- Mild hypertension controlled by diet
- History of a minor sprain
Correct 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.
CRC Medicare Advantage Payment Methodology 2
What is 'upcoding' in the context of Medicare Advantage?