CCRC Exam Study Guide With Complete Solutions
What is predictive modeling?
a. An analytical review of known data elements to establish a hypothesis
... [Show More] related to the
future health of patients.
b. An analytical review of payments to health plans to determine the cost of future
healthcare.
c. An average of costs associated with diagnoses used to determine which providers to
contract with for a health plan.
d. An average payment associated with diagnoses used to determine which health plans
providers should contract with. - a. An analytical review of known data elements to establish
a hypothesis related to the future health of patients.
Who developed and maintains HEDIS?
a. CMS
b. OIG
c. BCBS
d. NCQA - d. NCQA
What do the Star Ratings identify?
a. Top performing health plans based on quality
b. Top performing doctors based on quality
c. Cost of healthcare in facilities
d. Cost of healthcare by provider - a. Top performing health plans based on quality
What is the goal of HEDIS?
a. Allow for patients to rate their physicians.
b. Allow patients to compare health plans.
c. Allow patients to schedule appointments online.
d. Allow patients to access their medical records. - b. Allow patients to compare health
plans.
When are Star Ratings are publicly published?
a. January of each year.
b. January and June of each year.
c. October of each year.
d. April and October of each year - c. October of each year.
How is predictive modeling used in risk adjustment?
a. Determine the RAF score in HCC compared to FFS.
b. Determine suspected diagnoses based on data elements.
c. Determine the correct enrollment process.
d. Determine the return on investment for hiring coders. - b. Determine suspected
diagnoses based on data elements.
If you were using predictive modeling and the results were:
• Rx Claim: Albuterol (quick-relief inhaler)
• Medical Claim: Pulmonary Function Test
• DME claim: Home Nebulizer
a. Diabetes mellitus
b. Asthma
c. Osteoporosis
d. Hypertension - b. Asthma
If you were using a predictive model and the results were:
• The member had a DME claim for a cane.
• The member had an Rx Claim for a Fosamax.
• The member had a medical claim for a bone density scan.Which diagnosis would you
predict this member has?
a. Osteoarthritis
b. Degenerative joint disease of the knee
c. Spinal Stenosis
d. Osteoporosis - d. Osteoporosis
Which statement is TRUE regarding predictive modeling?
a. Predictive models are only used to identify patients who develop comorbidities due to a
lack of care.
b. Health plans often use predictive modeling to anticipate potential future diagnoses for an
individual patient.
c. Predictive modeling identifies needs a patient had in the past that was not provided.
d. Providers can use predictive modeling to identify when additional staff is required. - b.
Health plans often use predictive modeling to anticipate potential future diagnoses for an
individual patient.
How is predictive modeling used in risk adjustment? - to determine suspected diagnosis
based on data elements.
Which of the following data elements are used in predictive modeling?
I. DME claims
II. Prescription drug events
III. Physician claims data
IV. Facility claims data
a. III and IV
b. I, II, and IV
c. I, II, and III
d. I, II, III, and IV - d. I, II, III, and IV
What might happen as a result of predictive modeling?
a. Disease management programs
b. Concurrent audits
c. Transporation benefits
d. Reduction in case management - a. Disease management programs
In the CMS Star Ratings program, which measure is given the highest weight?
a. Outcomes
b. Patient experience
c. Customer service
d. Accurate RAF scores - a. Outcomes
How often are HEDIS measures revised?
a. As needed
b. Monthly
c. Bi-annually
d. Annually - d. Annually [Show Less]