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Exam (elaborations)

CDEO Chapter 8 Study Guide with Complete Solutions

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CDEO Chapter 8 Study Guide with Complete Solutions PREDICTIVE MODELING - Answer️️ -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 - Answer️️ -Many organizations utilize a ...

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  • September 13, 2024
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  • 2024/2025
  • Exam (elaborations)
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CDEO Chapter 8 Study Guide with
Complete Solutions
PREDICTIVE MODELING - Answer✔️✔️-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 - Answer✔️✔️-Many organizations utilize a method such as this one to

uncover diagnoses which are likely present but unreported or unknown

Chart Reviews - Answer✔️✔️-Analysis of the information identified is used to target

retrospective reviews to capture any unreported diagnoses

Suspect Logic Factors - Answer✔️✔️-* 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 - Answer✔️✔️-Quality Measures

Star Ratings

HEDIS - Answer✔️✔️-Healthcare Effectiveness Data and Information Set



Page | 1

, ©SOPHIABENNETT EXAM SOLUTIONS_2024/2025 Monday, September 2, 2024 12:59 PM


CMS Stars Ratings - Answer✔️✔️-

QBPs - Answer✔️✔️-Quality Bonus Payments

Quality Bonus Payments - Answer✔️✔️-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 - Answer✔️✔️-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 - Answer✔️✔️-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 - Answer✔️✔️-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.
Page | 2

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