CRC Medicare Advantage Payment Methodology

Question 1

What is the primary purpose of risk adjustment in Medicare Advantage?

Accepted Answer

To ensure plans are paid appropriately based on enrollee health status

Answer

To reduce provider payments

Answer

To eliminate duplicate claims

Answer

To increase Medicare premiums

Question 2

What does the CMS-HCC model use to predict?

Accepted Answer

Future healthcare expenditures

Answer

Patient satisfaction scores

Answer

Hospital readmission rates

Answer

Prescription drug usage only

Question 3

Which data source does CMS primarily use to calculate risk scores for MA plans?

Accepted Answer

Both FFS claims and encounter data submitted by MA plans

Answer

Hospital discharge data only

Answer

Fee-for-service Medicare claims only

Answer

Encounter data submitted by MA plans only

Question 4

What is the 'normalization factor' in Medicare Advantage risk adjustment?

Accepted Answer

A factor applied to ensure average risk scores across the program equal 1.0

Answer

A penalty for poor documentation

Answer

A bonus payment for preventive care

Answer

The standard rate for all enrollees

Question 5

What is the 'frailty adjuster' in Medicare Advantage risk adjustment?

Accepted Answer

An additional payment for enrollees in institutional settings

Answer

A reduction in payment for healthy enrollees

Answer

A penalty for incomplete documentation

Answer

A bonus for preventive screenings

Question 6

Which year's diagnosis data is used to calculate risk scores for the following payment year in Medicare Advantage?

Accepted Answer

One year prior to the payment year

Answer

Same year as payment

Answer

Two years prior to the payment year

Answer

Three years prior to the payment year