AAPC-CRC Certified Risk Adjustment Coder - Set 4 - Part 3

Correct Answer: Medicare covered items and services for which Medicare is not the primary payer

42 CFR 422.310(c)(1)(ii) requires risk adjustment data, to the extent CMS requires, to account for Medicare covered items and services for which Medicare is not the primary payer, in addition to the other listed categories. Option a is incorrect because the regulation lists items and services covered under the original Medicare program, not excluded ones, so excluded services do not appear among the required categories. Option b is incorrect because the regulation does not sort required data by contract status of the provider; its categories rest on coverage and payer status. Option d is incorrect because enrollee-paid services are not one of the three categories in the regulation, which names covered services, secondary-payer services and supplemental benefits.

Correct Answer: Chief financial officer

Under 42 CFR 422.504(l), the CEO, the CFO, or a delegate who reports directly to one of them must certify, on the payment request, that the data CMS requests are accurate, complete, and truthful. Option b is incorrect because the regulation names the CEO, the CFO, or a delegate reporting directly to one of them; a compliance officer is not listed as a signer. Option c is incorrect because this clinical role is not among the officers who may certify payment data; the authority sits with the CEO or CFO and their direct-report delegates. Option d is incorrect because a contracted auditor is an outside party, not an officer or a delegate who reports directly to the CEO or CFO as the regulation requires.

Correct Answer: An obligation under the False Claims Act

Under the enforcement provision, any overpayment an MA organization retains is an obligation under the False Claims Act statute if it is not reported and returned within the 60-day timeframe. Option a is incorrect because a bid submission is a separate document whose accuracy an executive certifies; the enforcement provision does not convert retained funds into one. Option b is incorrect because reconciliation is applied before funds are classed as an overpayment, since the definition counts only amounts the organization is not entitled to after reconciliation. Option d is incorrect because a payment request is the certified document an organization submits under its contract, which is unrelated to the consequence of keeping an unreported overpayment.

Correct Answer: Unsupported or invalid diagnosis codes, and overpayments

OIG guidance states that MAOs and other MA Parties must report to CMS unsupported and otherwise invalid diagnosis codes through designated systems, and overpayments in accordance with Medicare overpayment law and the Part C and D overpayment rule. Option a is incorrect because benchmarking and coding intensity analysis are internal monitoring tools used to find outliers, not the two items the guidance requires MAOs to report to CMS. Option b is incorrect because contract termination is a corrective action MA Parties should take after reviews, and the guidance does not list it or hotline allegations as required reports to CMS. Option c is incorrect because self-audit results are reported to the MAO by FDRs under contract provisions, and committee minutes are not named as a required report to CMS.

Correct Answer: Coding intensity analysis

OIG guidance describes analyzing providers' coding intensity, focusing particularly on changes or outliers with respect to specific codes or other trends. A sharp rise in one code across providers is exactly what this method screens for. Option b is incorrect because reporting overpayments is a required step after unsupported diagnoses are identified, so it follows the analysis and does not detect code-level changes. Option c is incorrect because a hotline investigation responds to allegations of provider or contractor fraud rather than screening submitted data for changes in how often particular codes are reported. Option d is incorrect because provider contract termination is a corrective action taken after investigations or reviews, not an analytic method that screens diagnosis data for shifts.

Correct Answer: Follow-up audits, education, and corrective action

When algorithms identify providers coding at higher rates than similar providers, OIG guidance calls for conducting follow-up audits, education, and appropriate corrective action, including submitting data to CMS for payment adjustments where needed. Option a is incorrect because the MAO is expected to promptly respond to detected problems itself, such as by expanding audit scope, rather than rest on a provider's assurance. Option c is incorrect because contract termination is named as one possible corrective action based on investigation or review results, not an automatic first response to an outlier. Option d is incorrect because OIG guidance describes audits, education, and submitting data to CMS for payment adjustments; it does not describe deleting records as a response.

Correct Answer: Assess a charge on the plan

The statute requires each State to assess a charge on health plans and health insurance issuers when the actuarial risk of their enrollees for a year is less than the State average actuarial risk. Option b is incorrect because payments go to plans whose enrollees' actuarial risk is greater than the State average, which is the opposite situation from the one described. Option c is incorrect because the statute sets no exemption for low-risk plans; it directs a charge on them when they fall below the State average. Option d is incorrect because the Secretary's role is to establish criteria and methods in consultation with States, not to receive referrals of low-risk plans.

Correct Answer: Self-insured group health plans

The statute sets the State average actuarial risk using enrollees in plans that are not self-insured group health plans, which are subject to ERISA. Self-insured group health plans are therefore excluded from the average risk comparison. Option a is incorrect because issuers providing health insurance coverage are the entities the statute directs States to charge or pay, so their enrollees stay in the average. Option b is incorrect because high actuarial risk plans receive State payments, and the statute includes their enrollees in the same State average rather than excluding them. Option c is incorrect because low actuarial risk plans are the ones assessed a charge under the statute, and their enrollees are counted in the State average.

Correct Answer: Providing comparative plan quality information to beneficiaries

Under the regulation on the Medicare Advantage Quality Rating System, CMS uses the ratings to give beneficiaries comparative information on plan quality and performance, supporting knowledgeable enrollment and coverage decisions in the Medicare program. Option a is incorrect because the bid is prepared by the MA organization, and the records rules tie bid data to financial auditing, not to the purposes of the ratings. Option c is incorrect because periodic auditing of financial records is a purpose of the record maintenance requirement in the contract provisions, not a use of the quality ratings. Option d is incorrect because premium rates for State insurance agency purposes appear in the record-keeping requirements for MA organizations, not among the stated uses of quality ratings.

Correct Answer: Coordinating work and sharing information

OIG guidance calls coordination and communication the compliance officer's key tools. Coordinating work and sharing information with leaders of functions such as Quality and Risk Management enhances the strength and success of the compliance program. Option b is incorrect because nothing in the guidance gives the compliance officer budget or staffing control over other support functions; the stated link is coordination and information sharing. Option c is incorrect because OIG guidance gives the compliance officer authority to interview anyone or designate a person for interviews, not to hand investigations over to support function leaders. Option d is incorrect because the compliance officer is to report to the CEO with direct access to the board, or to the board directly.