CRC Compliance & Regulatory Requirements 2

Question 1

Under the 60-Day Overpayment Rule, when does the 60-day clock begin for an MA plan discovering risk adjustment overpayments?

Accepted Answer

When the plan first identifies or should have identified the overpayment through reasonable diligence

Answer

The clock starts when the overpayment is identified or should have been identified. Plans cannot delay audits to delay the clock.

Question 2

An MA plan contracts with a vendor for retrospective chart reviews. Which OIG compliance concern is most relevant?

Accepted Answer

Prohibition on upcoding if the vendor is incentivized to find diagnoses regardless of support

Answer

Chart review vendors paid to find HCC gaps have an inherent incentive to add diagnoses that may not be fully supported.

Question 3

Which regulatory body has primary authority over Medicare Advantage risk adjustment compliance?

Accepted Answer

CMS through its Center for Program Integrity

Answer

CMS/CPI administers RADV, sets data submission requirements, and enforces compliance. DOJ may pursue FCA cases, but CMS is primary.

Question 4

A provider's documentation consistently uses copy-forward, resulting in identical problem lists across encounters. What compliance concern does this raise?

Accepted Answer

Significant concern that diagnoses may be perpetuated without active clinical assessment

Answer

Diagnoses may be perpetuated without the provider actively assessing whether each condition is still present and relevant.

Question 5

What is the minimum coding intensity adjustment CMS applies to MA risk adjustment payments?

Accepted Answer

A mandatory 5.91% reduction to all MA risk scores to account for MA-FFS coding differences

Answer

The 5.91% reduction accounts for the documented fact that MA plans capture more diagnoses than FFS Medicare.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Compliance & Regulatory Requirements 2