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
Suspect Logic - Many organizations utilize a method such as this one to uncover diagnoses which are likely present but unrepor...
CDEO Chapter 8 Study guide questions
and answers
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
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
CDEO Chapter 8 Study guide questions and answers
,CDEO Chapter 8 Study guide questions and answers
CMS Stars Ratings -
QBPs - Quality Bonus Payments
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.
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.
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
CDEO Chapter 8 Study guide questions and answers
, CDEO Chapter 8 Study guide questions and answers
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
Annual Flu Vaccine
Improving or Maintaining Physical Health
Improving or Maintaining Mental Health
Monitoring Physical Activity
Adult BMI Assessment
Medicare Advantage HMO Plan Part C: Domain 2 - Domain 2: Managing Chronic
Conditions (12 Measures)
-SNP Care Management
-Care for Older Adults - Medication Review
-Care for Older Adults - Functional Status ---Assessment
-Care for Older Adults - Pain Screening
-OMW
-CDC-EE
CDEO Chapter 8 Study guide questions and answers
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