CRC Prospective and Retrospective Risk Adjustment Strategies

Question 1

Which risk adjustment strategy involves reviewing medical records AFTER the date of service to identify and submit diagnoses that support HCC capture?

Accepted Answer

Retrospective coding

Answer

Prospective coding

Answer

Concurrent coding

Answer

Predictive modeling

Question 2

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?

Accepted Answer

Prospective risk adjustment

Answer

Retrospective chart review

Answer

RADV audit preparation

Answer

Supplemental data submission

Question 3

What is the primary goal of a 'chase program' in risk adjustment?

Accepted Answer

To identify members with suspected undocumented conditions and prompt provider outreach

Answer

To pursue outstanding premium payments from members

Answer

To chase down RADV audit results from CMS

Answer

To follow up on denied claims with payers

Question 4

Supplemental data sources used in retrospective risk adjustment most commonly include which of the following?

Accepted Answer

Medical records, lab data, and pharmacy data reviewed outside the normal claims flow

Answer

Lab results and pharmacy data only

Answer

Member satisfaction surveys

Answer

HEDIS reports and quality metrics

Question 5

Under Medicare Advantage risk adjustment, what is the diagnosis submission deadline for the prior benefit year under the retrospective data submission timeline?

Accepted Answer

March 31 of the current year

Answer

January 31 of the current year

Answer

September 30 of the prior year

Answer

February 14 of the current year

Question 6

Which of the following best describes a 'gap closure' activity in prospective risk adjustment?

Accepted Answer

Scheduling patients with chronic conditions for annual visits to document and code existing diagnoses

Answer

Submitting corrected claims for denied encounters

Answer

Filing appeals for rejected RADV audit findings

Answer

Reprocessing encounter data to fix submission errors

Question 7

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?

Accepted Answer

Prospective member targeting for outreach

Answer

RADV audit defense

Answer

Encounter data error correction

Answer

ICD-10-CM code validation