CRC Risk Adjustment Models Overview 2

Question 1

What is the primary purpose of hierarchies in the CMS-HCC model?

Accepted Answer

To eliminate redundant payment for related conditions by counting only the most severe

Answer

Hierarchies prevent double-counting within related disease groups. Only the highest-severity HCC is counted for payment.

Question 2

Which population does the HHS-HCC model serve, and what key structural difference exists from CMS-HCC?

Accepted Answer

ACA marketplace populations using concurrent rather than prospective risk adjustment

Answer

HHS-HCC serves ACA marketplace populations and uses concurrent risk adjustment (same-year diagnoses predict same-year costs).

Question 3

How is the RAF score calculated for a Medicare Advantage member?

Accepted Answer

A composite combining demographic factors, HCC weights, and disease interaction terms predicting expected costs relative to average

Answer

The RAF starts with a demographic baseline and adds incremental weights for HCCs and applicable disease interactions. A RAF of 1.0 equals average expected cost.

Question 4

What was the most significant change in the CMS-HCC V24 to V28 transition?

Accepted Answer

V28 reclassified condition categories, added new HCCs, and revised hierarchies for current medical practice

Answer

V28 involved significant reclassification: new HCCs, splits, merges, hierarchy revisions, and recalibrated weights.

Question 5

What is the 'normalization factor' in the CMS-HCC model?

Accepted Answer

A budget-neutrality adjustment preventing total MA payments from growing solely due to coding intensity

Answer

The normalization factor ensures aggregate payments remain budget-neutral as coding practices change.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Risk Adjustment Models Overview 2