CRC Medicare Advantage Payment Methodology 2

Question 1

What is 'upcoding' in the context of Medicare Advantage?

Accepted Answer

Reporting higher-severity diagnoses than documented to inflate risk scores

Answer

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:

Accepted Answer

County-level fee-for-service Medicare spending rates

Answer

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?

Accepted Answer

Additional payment for plans with 4 or more stars on the CMS Star Rating

Answer

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?

Accepted Answer

New enrollee model using only demographic factors

Answer

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?

Accepted Answer

Monitoring year-over-year changes in risk scores to identify documentation patterns

Answer

Risk score trending monitors year-over-year changes to identify patterns indicating potential upcoding or documentation improvement opportunities.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Medicare Advantage Payment Methodology 2