R
The legal entity that owns a controlling interest in a Medicare Advantage Organization (MAO).
Parent Organization
What is the calculation of payment error for a larger population based on enrollee-level payment error findings?
Extrapolation
A group of Medicare Advantage enrollees selected by CMS for Medical Record (MR) review to verify the accuracy of diagnosis data submitted by the plan for RADV.
Sample
This number predicts a patient’s expected healthcare costs relative to the average Medicare beneficiary, based on demographics and documented health conditions.
Risk Score
This standardized medical coding system is used by healthcare professionals to code diagnoses, symptoms, and procedures for claims processing.
International Classification of Diseases (ICD)
In the CMS risk-adjustment model for Medicare Advantage, this three-letter acronym groups related diagnoses into a single risk group to help predict future costs and set reimbursement.
Hierarchical Condition Category (HCC)
This term refers to the group of enrollees within a Medicare Advantage Organization (MAO) subject to audit and analysis.
Eligible Population
The difference between total net overpayment and total net underpayments.
Enrollee Net Payment Error (ENET)
This term means a person registered in a health program, whether or not they’ve used any medical services.
Enrollee
Described as “the single source of transactional data for the entire audit and appeals process”
Central Data Abstraction Tool (CDAT)
In statistics, this refers to the probability that a particular population parameter will fall between a set of values, a certain proportion of time
Confidence Interval
This term refers to an enrolled person who has received at least one covered medical service during a defined period.
Beneficiary
This is a formal written artifact that specifies CMS’ technical demands and logical expectations for a deliverable.
Requirements Document
This validation finding occurs when an audited CMS Hierarchical Condition Category (CMS-HCC) does not have a medical record abstracted in CDAT containing an ICD-9-CM/ICD-10-CM that maps to the same CMS-HCC
Discrepant
These metrics analyze enrollee-level trends by tracking groups of CMS Hierarchical Condition Categories (CMS-HCCs) over multiple years.
Disease Persistency Pattern Metrics
A binary variable – takes the value of 0 or 1 – to flag whether a specific condition is met
Indicator
A voluntary outpatient prescription drug benefit for Medicare eligible beneficiaries, provided through private plans that contract with the federal government
Medicare Part D
Used commonly by the Business Intelligence (BI) workstream as a prototype/mockup of a dashboard/report for the purpose of visual demonstration
Wireframe
This term refers to a distinct subgroup of a population, created so researchers can draw a random sample from each subgroup.
Stratum
Information submitted by health care providers, such as doctors or hospitals, that documents both the clinical conditions they diagnose as well as the services/items delivered to treat conditions
Encounter Data
This collaborative version-control platform is used by the LAC team daily to manage and back up source code.
GitHub
In Medicare coverage, these beneficiaries change enrollment from one plan to another or move between Traditional Medicare and a Medicare Advantage (MA) plan.
Switchers
This type of predictive model is inspired by how the human brain processes information.
Neural Network
A group of a population based on a shared property, characteristic, or event, such as a year of birth or year of marriage
Cohort
This is the process of aligning the change in risk score predictions for a RADV Eligible Population with a distribution of historical audit results.
Calibration