CRC Prospective and Retrospective Risk Adjustment Strategies 2 — Questions and Answers
Question 1: What is the key distinction between prospective and retrospective risk adjustment activities from a compliance standpoint?
- Prospective activities are always compliant; retrospective activities are not
- Retrospective activities must be supported by face-to-face encounter documentation; prospective activities occur during live patient visits (Correct answer)
- Prospective activities require CMS pre-approval; retrospective activities do not
- There is no compliance difference between the two strategies
Correct answer: Retrospective activities must be supported by face-to-face encounter documentation; prospective activities occur during live patient visits
Retrospective diagnoses must be supported by valid face-to-face encounter documentation; prospective activities capture diagnoses during actual patient encounters, making both compliant when properly documented.
Question 2: Which of the following is a risk associated with relying solely on retrospective chart reviews for risk adjustment?
- Risk scores are always higher than with prospective methods
- Diagnoses found may lack face-to-face encounter documentation required by CMS (Correct answer)
- CMS prohibits retrospective submissions entirely
- Retrospective coding eliminates the need for provider education
Correct answer: Diagnoses found may lack face-to-face encounter documentation required by CMS
A key risk of retrospective reviews is discovering diagnoses in records that were never linked to a valid face-to-face encounter, which CMS requires for HCC capture under Medicare Advantage.
Question 3: Provider education is a critical component of prospective risk adjustment because it:
- Eliminates the need for chart reviews
- Ensures providers document the specificity and acuity of chronic conditions during patient encounters (Correct answer)
- Replaces the need to submit encounter data to CMS
- Allows health plans to self-report risk scores without provider input
Correct answer: Ensures providers document the specificity and acuity of chronic conditions during patient encounters
Provider education in prospective risk adjustment focuses on teaching clinicians to document chronic conditions with appropriate specificity and acuity so that diagnoses are captured accurately during encounters.
Question 4: A health plan identifies that many of its members with COPD do not have a COPD diagnosis in their encounter data despite having inhalers on their pharmacy records. The BEST first step in a prospective strategy is to:
- Submit the pharmacy data directly to CMS as a diagnosis
- Work with providers to schedule these members for visits and ensure COPD is documented if clinically supported (Correct answer)
- Add the COPD ICD-10-CM code to the encounters retroactively
- Report the gap to the OIG for investigation
Correct answer: Work with providers to schedule these members for visits and ensure COPD is documented if clinically supported
The prospective approach is to engage providers to schedule affected members, confirm the diagnosis clinically, and ensure it is properly documented during a face-to-face encounter.
Question 5: In retrospective risk adjustment, what does 'medical record abstraction' involve?
- Summarizing member satisfaction feedback from medical records
- Reviewing clinical records to identify diagnoses that support HCC capture and were not submitted via encounter data (Correct answer)
- Abstracting data from CMS payment files for actuarial purposes
- Removing outdated diagnoses from encounter submissions
Correct answer: Reviewing clinical records to identify diagnoses that support HCC capture and were not submitted via encounter data
Medical record abstraction in retrospective risk adjustment involves trained coders reviewing clinical documentation to identify HCC-relevant diagnoses that may not have been captured in the original encounter submission.
Question 6: Which of the following statements about the timing of risk adjustment data submission is CORRECT?
- All risk adjustment data must be submitted prospectively before the benefit year begins
- Diagnoses from the benefit year can be submitted on an ongoing basis throughout the year and up to the final sweep deadline (Correct answer)
- CMS only accepts risk adjustment data submissions once per year in January
- Retrospective submissions are not accepted by CMS after July of the benefit year
Correct answer: Diagnoses from the benefit year can be submitted on an ongoing basis throughout the year and up to the final sweep deadline
Medicare Advantage plans can submit encounter data on an ongoing basis throughout the benefit year and into the following year up to the final risk score reconciliation deadline.
Question 7: A health plan's risk adjustment strategy includes both prospective outreach AND retrospective chart review. The PRIMARY advantage of this combined approach is:
- It reduces the plan's premium payments to CMS
- It maximizes HCC capture by addressing gaps both during and after the service year (Correct answer)
- It eliminates the need for RADV audit readiness
- It allows the plan to bypass standard encounter data submission requirements
Correct answer: It maximizes HCC capture by addressing gaps both during and after the service year
A combined prospective and retrospective strategy is most effective because it captures diagnoses during care delivery while also ensuring that any gaps missed prospectively are identified through post-service chart review.
CRC Prospective and Retrospective Risk Adjustment Strategies 2
What is the key distinction between prospective and retrospective risk adjustment activities from a compliance standpoint?