Certified Risk Adjustment Coder (CRC)

How is the fee-for-services (FFS) data used for purposes of risk adjustment?

1. The FFS reimbursement is used to determine the RAF score.

2. The FFS data is used to determine which patient should be enrolled in the RA plan.

3. The average FFS expenses and rates are used to determine the FFS normalization adjustment.

4. The average FFS expenses and rates are used to determine the maximum payment per RAF score.

The correct answer is: The average FFS expenses and rates are used to determine the FFS normalization adjustment.

The average fee-for-service (FFS) expenses and rates are utilized to determine the FFS normalization adjustment. This process is essential in risk adjustment models as it helps to normalize data across different providers and services. The normalization adjustment accounts for variations in FFS expenditures, ensuring the data accurately reflects the costs associated with patient care. By using average FFS expenses and rates, the normalization adjustment can effectively standardize payment rates and expenditures against a baseline, which is critical for the consistent evaluation of risk scores across different populations and settings. This helps maintain fairness in the risk adjustment process by providing a clear benchmark for reimbursement based on the overall costs of care, rather than individual provider variations. In contrast, the other options do not accurately represent the specific role of FFS data in risk adjustment. The use of FFS reimbursement to determine the RAF score pertains more directly to payment models rather than the normalization process. Similarly, determining which patients should be enrolled in a risk adjustment plan relates more to eligibility criteria rather than FFS data itself. Lastly, while maximum payment per RAF score involves payment models, it does not specifically hinge on the average expenses and rates that form the basis for normalization.