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

To rank codes by billing frequency

Answer

To organize medical specialties by cost contribution

Answer

To establish documentation priority order

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

Medicaid populations with 5-year age bands

Answer

Medicare Supplement populations with prescription drug data

Answer

Federal Employee Health Benefit populations with provider specialty variables

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

Age and gender only

Answer

Total ICD-10-CM codes divided by encounters

Answer

A quality score based on preventive care adherence

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 added prescription drug data

Answer

V28 eliminated disease interaction terms

Answer

V28 changed from prospective to concurrent approach

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

A factor adjusting for regional cost differences

Answer

A quality adjustment factor for Star Ratings

Answer

A demographic correction for plan member age

Question 6

How do 'new enrollee' models differ from 'continuing enrollee' models?

Accepted Answer

New enrollees rely on demographic factors only because no prior history is available; continuing enrollees use prior year HCC data

Answer

New enrollee models use prior plan's diagnosis data

Answer

There is no distinction between the models

Answer

New enrollee models use higher RAF weights for uncertainty