AAPC-CRC Certified Risk Adjustment Coder - Set 5 - Part 1

Correct Answer: Setting enrollee cost-sharing levels

The regulation lists three purposes: comparative information for beneficiaries, 5-star ratings for quality bonus payment status and rebate retention allowances, and oversight of compliance. Setting enrollee cost-sharing levels is not among them. Option b is incorrect because the regulation gives ratings a role as a means of evaluating and overseeing overall and specific compliance with certain regulatory and contract requirements by MA plans. Option c is incorrect because the 5-star rating system is expressly used in determining quality bonus payment status, along with rebate retention allowances, so this is a stated purpose. Option d is incorrect because it is the first listed purpose: CMS provides comparative plan quality and performance information so beneficiaries can make knowledgeable enrollment and coverage decisions.

Correct Answer: Access to facilities and records

The excerpt gives HHS, the Comptroller General, or their designee authority to evaluate services through inspection, audit, or other means, which is the contract's access to facilities and records requirement. Option a is incorrect because it obliges the MA organization to keep books and records for 10 years so CMS can audit, rather than granting evaluators their authority. Option c is incorrect because it covers the elements of a plan's chronic care program and populations identified by CMS, not inspection or audit authority of HHS. Option d is incorrect because it requires each MA plan to run an ongoing quality improvement program, an internal duty of the organization rather than an outside evaluation right.

Correct Answer: It alerts the entity to concerns and helps mitigate risk of patient harm

OIG guidance states that integrating quality and patient safety oversight into compliance processes can alert the entity to concerns and enable it to mitigate risk of patient harm. Entities should therefore incorporate this oversight into their compliance programs. Option a is incorrect because the guidance says the board should require regular reports from senior leadership, so oversight adds to board involvement rather than ending it. Option b is incorrect because quality of care is listed as its own common compliance risk area beside billing and coding, so adding it widens the program's scope. Option c is incorrect because OIG guidance still calls for a designated compliance officer with authority, stature, access and resources, so quality oversight does not substitute for that role.

Correct Answer: I, II, and III

OIG states that an effective compliance program reduces and mitigates risk, provides patients safe and high-quality care, and saves costs. Statement IV conflicts with guidance to coordinate with Quality and Risk Management functions. Option a is incorrect because it leaves out cost savings, which OIG also names as an outcome of an effective compliance program alongside risk reduction and safe care. Option b is incorrect because statement IV is not an outcome OIG lists; the guidance encourages sharing information with Quality and Risk Management leaders, not dropping that coordination. Option d is incorrect because it includes statement IV, which contradicts OIG's advice to coordinate with Quality and Risk Management, and it omits the safe, high-quality care outcome.

Correct Answer: Conducting root-cause analyses

OIG guidance says the Compliance Committee's quality audit and review program should audit incidents, conduct root-cause analyses, design or approve corrective action plans, and track the plans' implementation and effectiveness. Option a is incorrect because reimbursement schedules are not part of OIG's description of quality audits and reviews, which concern incidents, causes, corrective plans and tracking. Option b is incorrect because the compliance officer keeps a separate responsibility for implementing the compliance program, and the committee's audit program does not take that role over. Option c is incorrect because a quality dashboard is an optional board tool for monitoring quality performance, not a listed element of the committee's audit and review program.

Correct Answer: Review by an appropriately credentialed clinician

OIG guidance says Medicare requires items and services to be medically reasonable and necessary, so claims reviews and audits should include a medical necessity review by an appropriately credentialed clinician. Without it, important concerns may go unidentified. Option a is incorrect because the guidance names a credentialed clinician for medical necessity, and legal counsel is not described as the reviewer for that question. Option b is incorrect because the board receives regular reports on quality and patient safety oversight; the guidance does not assign it to perform claims-level medical necessity reviews. Option d is incorrect because the compliance officer implements the program and shares work with clinical leadership, but the guidance does not make that role the sole medical necessity reviewer.

Correct Answer: Independent monitor with clinical expertise

OIG guidance states that cases involving quality-of-care issues may result in a CIA with an independent monitor with clinical expertise, who examines the entity's delivery of care and its ability to prevent, detect, and respond to patient care problems. Option a is incorrect because a claims review is tied to cases of fraudulent billing, which differ from cases centered on patient care problems. Option b is incorrect because this review fits a case involving a Federal anti-kickback statute or PSL violation, so it addresses a different underlying conduct. Option c is incorrect because this is a requirement typical of CIAs for pharmaceutical and device manufacturers to oversee sales force activities, not a quality-of-care feature.

Correct Answer: A quality measure

Query titles, tracking identifiers, or subject lines visible to providers must be nonleading and must not reference a specific desired diagnosis, reimbursement impact, or quality measure. This applies to technology-generated queries just as to manual ones. Option a is incorrect because the guidance requires technology-generated answer options to include an "other" choice or an alternate explanation, so this is a required feature rather than a prohibited reference. Option c is incorrect because citing where indicators appear is part of what technology-generated queries must do for clinical indicators, not a restriction placed on titles or subject lines. Option d is incorrect because clinical indicators are required content in technology-generated queries, sourced from the health record and cited with location, so they are not prohibited in the title context.

Correct Answer: Provider opportunity for independent clinical judgment

Substantial compliance means a query is nonleading, includes clinically relevant and sourced indicators, does not reference reimbursement or quality outcomes, and gives the provider an opportunity to exercise independent clinical judgment. That last element is the one missing here. Option b is incorrect because substantial compliance requires that a query not reference reimbursement or quality outcomes, so naming a measure would move the query away from compliance rather than toward it. Option c is incorrect because query titles and subject lines visible to providers must be nonleading, and a title that names a specific desired diagnosis would be leading. Option d is incorrect because a compliant query leaves reimbursement out entirely, because queries serve clinical accuracy and integrity and are not a mechanism to influence payment.

Correct Answer: Health status and demographic characteristics

CMS uses risk adjustment to adjust bidding and payment based on the health status and demographic characteristics of an enrollee, so plans are paid for the risk of the beneficiaries they enroll. Option a is incorrect because CMS replaces an average amount for Medicare beneficiaries with a payment reflecting enrollee risk, so an average-cost basis is what risk adjustment moves away from. Option b is incorrect because neither of these describes the enrollee; CMS bases the adjustment on the beneficiary's own health and demographic profile, not on who delivers care or where. Option c is incorrect because these describe the plan or its enrollment, whereas risk adjustment measures the relative risk of each individual beneficiary the plan enrolls.

Correct Answer: Standardize bids for the average Medicare beneficiary

CMS uses risk adjustment to standardize bids so that each plan has a bid for the average Medicare beneficiary. Standardized bids then serve as base payments to plans, which are adjusted by risk scores. Option b is incorrect because risk adjustment does the opposite, letting CMS pay plans for the risk of the beneficiaries they enroll instead of an average amount. Option c is incorrect because CMS developed separate models for Parts A and B benefits under Part C and for Part D, each with segments. Option d is incorrect because demographic characteristics such as age and gender are used with health status (diagnostic data) to calculate risk scores and adjust payments and bids.

Correct Answer: Standardized bids

By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans. Standardizing gives each plan a bid for the average Medicare beneficiary, so bids can be compared across differing populations. Option a is incorrect because premiums are amounts charged to enrollees, whereas the base payment to a plan comes from its bid once that bid has been risk adjusted. Option c is incorrect because diagnostic data is an input to risk scores, which measure relative risk, so it is not a payment amount and is not what serves as the base. Option d is incorrect because paying an average amount for all beneficiaries is what risk adjustment replaces, since it lets CMS pay plans for the risk of the enrollees they actually enroll.

Correct Answer: 30 days

Under the charge submission deadline in 45 CFR 153.610(e), an issuer must remit net charges to the State, or HHS on behalf of the State, within 30 days of notification of net charges payable. Option b is incorrect because ten years is how long an issuer must maintain documents and records for each benefit year, which is a retention rule rather than a payment deadline. Option c is incorrect because the regulation sets no sixty-day period for remitting net charges; the deadline is shorter and runs from the notification of net charges payable. Option d is incorrect because fifteen calendar days is the window for responding to audit notices, letters, and inquiries, not the deadline for remitting net risk adjustment charges.

Correct Answer: Fee-for-service treatment and coding changes, and MA versus Part A and B coding patterns

The statute and 42 CFR 422.308(c)(5)(i) require the coding adjustment to reflect changes in treatment and coding practices in the fee-for-service sector and differences in coding patterns between MA plans and providers under Part A and B. Option a is incorrect because these relate to the risk score used for certain special needs individuals in specialized MA plans, which is a separate provision from the coding adjustment. Option c is incorrect because frailty and institutional status are risk adjustment factors or evaluation topics elsewhere in the guidance, not the differences the coding adjustment is required to reflect. Option d is incorrect because inpatient hospital and ambulatory settings are the data basis for the risk adjustment methodology, not the two differences the coding adjustment must reflect, and enrollment growth is not named.

Correct Answer: HHS, on behalf of the State

Under the regulation, a State that does not elect to operate an Exchange forgoes all State functions in the risk adjustment subpart, and HHS carries out all of those provisions on behalf of the State. Option b is incorrect because this office may request documents and records for review, which is an oversight access role rather than administration of risk adjustment for a State. Option c is incorrect because the OIG is named as an entity that may request State risk adjustment records, not as the party carrying out State functions. Option d is incorrect because a State without an Exchange forgoes all State functions in the subpart, so it has no program through which to select an entity.

Correct Answer: Uniformly, to all types of plans

The regulation's uniform application rule states that CMS applies the health status adjustment factor to all types of plans, with a stated exception for MA RFB plans. Option a is incorrect because the regulation applies the factor to all types of plans; special needs individuals are addressed only through a separate risk score rule for certain new enrollees. Option c is incorrect because coding pattern differences feed a coding adjustment to payment, which is separate from the rule that the health status factor itself applies uniformly. Option d is incorrect because frailty adjustment authority under PACE payment rules is a distinct provision, and it does not limit which plan types receive the health status factor.

Correct Answer: actuarial equivalence

The statute requires the Secretary to adjust payment amounts for age, disability status, gender, institutional status and other factors, including health status, so as to ensure actuarial equivalence. The Secretary may add to, modify or substitute for factors to improve it. Option a is incorrect because this phrase does not appear in the statute's description of the adjustment's goal, which is actuarial equivalence rather than matching fee-for-service payment levels. Option b is incorrect because nothing in the adjustment provision ties age, disability, gender or institutional factors to keeping enrollment steady; the stated aim concerns actuarial soundness of payment. Option c is incorrect because the statute does not name this as the purpose of the demographic adjustment; its coding adjustment addresses differences in coding patterns between Medicare Advantage and fee-for-service.

Correct Answer: Paying providers a fee for each submitted risk adjustment record

The regulation requires electronic submission, obtaining data from the furnishing provider, and an NPI on each encounter record. It says nothing about MA organizations paying a fee per submitted record; contract provisions it allows concern financial penalties for incomplete data. Option a is incorrect because the regulation directs MA organizations to obtain the required data from the provider, supplier, physician, or other practitioner who furnished the item or service. Option b is incorrect because the regulation states that the data must be submitted electronically to the appropriate CMS contractor, so this is a stated requirement. Option d is incorrect because the regulation requires an NPI in a billing provider field on each MA encounter data record, per CMS guidance, so it is required.

Correct Answer: Inpatient hospital stays

The Balanced Budget Act required risk adjustment to be based initially only on data from enrollees' inpatient hospital stays, with later implementation using data from additional sites of care. Option a is incorrect because physician data belonged to the ambulatory risk adjustment submission that began later, once additional sites of care were added to the model. Option b is incorrect because demographics alone described the pre-BBA payment method, which risk adjustment was meant to replace in part, so it was not a health status data source. Option c is incorrect because outpatient hospital data was part of the ambulatory submission introduced later, so it was not the initial basis for risk adjustment.

Correct Answer: Balanced Budget Act

The Balanced Budget Act mandated that a risk adjustment payment methodology incorporating beneficiaries' health status be implemented in the Medicare+Choice program, now the Medicare Advantage program, initially using inpatient hospital stay data. Option b is incorrect because HIPAA does not appear in the guidance on the history of Medicare Advantage risk adjustment, so it did not mandate a health status payment method. Option c is incorrect because it required risk adjustment models to use diagnoses from ambulatory settings in addition to inpatient stays, extending the original mandate rather than creating it. Option d is incorrect because it extended prescription drug coverage, renamed Medicare+Choice as Medicare Advantage, set up bidding and added Part D risk adjustment, but did not originate the health status mandate.