Risk Adjustment Models Overview Flashcards
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Read the first 6 Risk Adjustment Models Overview flashcards as text
What is the primary purpose of hierarchies in the CMS-HCC model?
Answer: To eliminate redundant payment for related conditions by counting only the most severe
Hierarchies prevent double-counting within related disease groups. Only the highest-severity HCC is counted for payment.
Which population does the HHS-HCC model serve, and what key structural difference exists from CMS-HCC?
Answer: ACA marketplace populations using concurrent rather than prospective risk adjustment
HHS-HCC serves ACA marketplace populations and uses concurrent risk adjustment (same-year diagnoses predict same-year costs).
How is the RAF score calculated for a Medicare Advantage member?
Answer: A composite combining demographic factors, HCC weights, and disease interaction terms predicting expected costs relative to average
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.
What was the most significant change in the CMS-HCC V24 to V28 transition?
Answer: V28 reclassified condition categories, added new HCCs, and revised hierarchies for current medical practice
V28 involved significant reclassification: new HCCs, splits, merges, hierarchy revisions, and recalibrated weights.
What is the 'normalization factor' in the CMS-HCC model?
Answer: A budget-neutrality adjustment preventing total MA payments from growing solely due to coding intensity
The normalization factor ensures aggregate payments remain budget-neutral as coding practices change.
How do 'new enrollee' models differ from 'continuing enrollee' models?
Answer: New enrollees rely on demographic factors only because no prior history is available; continuing enrollees use prior year HCC data
New enrollees have no prior MA claims history, so RAF is calculated from demographics only. Continuing enrollees get the full HCC-based calculation.