CRC Prospective and Retrospective Risk Adjustment Strategies 2

Question 1

What is the key distinction between prospective and retrospective risk adjustment activities from a compliance standpoint?

Accepted Answer

Retrospective activities must be supported by face-to-face encounter documentation; prospective activities occur during live patient visits

Answer

Prospective activities are always compliant; retrospective activities are not

Answer

Prospective activities require CMS pre-approval; retrospective activities do not

Answer

There is no compliance difference between the two strategies

Question 2

Which of the following is a risk associated with relying solely on retrospective chart reviews for risk adjustment?

Accepted Answer

Diagnoses found may lack face-to-face encounter documentation required by CMS

Answer

Risk scores are always higher than with prospective methods

Answer

CMS prohibits retrospective submissions entirely

Answer

Retrospective coding eliminates the need for provider education

Question 3

Provider education is a critical component of prospective risk adjustment because it:

Accepted Answer

Ensures providers document the specificity and acuity of chronic conditions during patient encounters

Answer

Eliminates the need for chart reviews

Answer

Replaces the need to submit encounter data to CMS

Answer

Allows health plans to self-report risk scores without provider input

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:

Accepted Answer

Work with providers to schedule these members for visits and ensure COPD is documented if clinically supported

Answer

Submit the pharmacy data directly to CMS as a diagnosis

Answer

Add the COPD ICD-10-CM code to the encounters retroactively

Answer

Report the gap to the OIG for investigation

Question 5

In retrospective risk adjustment, what does 'medical record abstraction' involve?

Accepted Answer

Reviewing clinical records to identify diagnoses that support HCC capture and were not submitted via encounter data

Answer

Summarizing member satisfaction feedback from medical records

Answer

Abstracting data from CMS payment files for actuarial purposes

Answer

Removing outdated diagnoses from encounter submissions

Question 6

Which of the following statements about the timing of risk adjustment data submission is CORRECT?

Accepted Answer

Diagnoses from the benefit year can be submitted on an ongoing basis throughout the year and up to the final sweep deadline

Answer

All risk adjustment data must be submitted prospectively before the benefit year begins

Answer

CMS only accepts risk adjustment data submissions once per year in January

Answer

Retrospective submissions are not accepted by CMS after July of the benefit year

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:

Accepted Answer

It maximizes HCC capture by addressing gaps both during and after the service year

Answer

It reduces the plan's premium payments to CMS

Answer

It eliminates the need for RADV audit readiness

Answer

It allows the plan to bypass standard encounter data submission requirements