CDEO Chapter 8 All Possible Questions and Answers with complete solution
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Course
CDEO Chapter 8
Institution
CDEO Chapter 8
Quality Bonus Payments - TO make quality of care a priority the Affordable Care Act set a
requirement that CMS make quality bonus payments to Medicare Advantage plans that earn four or
more stars in a five-star quality rating system would receive a bonus payment. Earning fewer than four
stars wo...
CDEO Chapter 8
Quality Bonus Payments - TO make quality of care a priority the Affordable Care Act set a
requirement that CMS make quality bonus payments to Medicare Advantage plans that earn four or
more stars in a five-star quality rating system would receive a bonus payment. Earning fewer than four
stars would receive no bonus.
Suspect Logic - Many organizations utilize a method such as this one to uncover diagnoses which
are likely present but unreported or unknown
Chart Reviews - Analysis of the information identified is used to target retrospective reviews to
capture any unreported diagnoses
Suspect Logic Factors - * Known/Expected clinical progression of an illness or disease
* DME needs
* PDE
* Laboratory test findings
* CPT codes reported during the year in review
* HCPCS codes reported during the year in review
* Socioeconomic status
* Disability: Hospice: ESRD and other such statuses of the patient being reviewed
Quality of Care - Quality Measures
Star Ratings
HEDIS - Healthcare Effectiveness Data and Information Set
CMS Stars Ratings -
, QBPs - Quality Bonus Payments
CMS Demonstration Period - Beginning in 2012, CMS conducted a nationwide 3 year
demonstration project where by a scaled bonus program was used, with the expectation that Medicare
Advantage organizations with three or more stars would push themselves toward earning four and five
star ratings. During this period, plans that were at or above three stars would receive quality bonus
payments based on a sliding scale.
PREDICTIVE MODELING - is an analytical review of known data elements to establish a hypothesis
related to the future health needs of patients or a population of patients
Star Ratings - the star ratings ranked plans on a calse from one to five stars, in half-star increments
defined in the following manner
* 5 STARS = EXCELLENT PERFORMANCE
* 4 STARS = ABOVE AVERAGE PERFORMANCE
* 3 STARS = AVERAGE PERFORMANCE
* 2 STARS = BELOW AVERAGE PERFORMANCE
* 1 STAR = POOR PERFORMANCE
Stars Ratings - are based on individual quality metrics or measures, variable weights are given to
each measure; those related to outcomes are weighted highest, followed by patient experience
measures and process measures.
Medicare Advantage Plans as well as Prescription Drug Plans, are equally tasked with these quality
measures.
Medicare Advantage HMO Plan Part C: Domain 1 - Domain 1: Staying Healthy- Screenings, Test,
and Vaccines (7 Measures)
Breast Cancer Screening
Colorectal Cancer Screeening
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