Ace the Certified Risk Adjustment Coder (CRC) Challenge 2026 – Crunch the Code and Rock Your Role!

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During a retrospective chart audit, if a diagnosis is not supported by medical records, what is the potential extrapolated cost saving for the health plan with 1,500 members?

$1,500

$350

$525,000

The potential extrapolated cost saving for the health plan with 1,500 members hinges on understanding the financial implications of unsupported diagnoses in medical records. When a diagnosis is not substantiated, it may lead to the removal of unnecessary or unsupported claims for services associated with that diagnosis. This can significantly impact the overall cost structure for health plans.

In this context, if a diagnosis is determined to be unsupported, the health plan could potentially save a substantial amount, represented by the number $525,000. This figure likely arises from calculating the average cost per member associated with the unsupported diagnoses and multiplying this by the total number of members (1,500). Such calculations are a standard procedure during audits to assess financial liabilities and gain a clearer picture of potential savings.

Health plans typically face financial risks associated with incorrect diagnoses, which can drive unnecessary costs if those diagnoses lead to inappropriate or unnecessary services being billed. The cost savings calculated in this scenario aim to reflect the cumulative financial impact of denying claims for unsupported diagnoses across the membership base.

While other options present various figures, they do not align with the expected cost savings seen in healthcare reimbursement models tied to diagnosis-related services. Therefore, the extrapolated cost saving accurately reflects a potential reduction in financial outlay for the health plan

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