Medicare Advantage at the tipping point
By Robert King – Fierce Healthcare Oct 10, 2022
Medicare Advantage is likely to make up more than half of total Medicare enrollment in 2023 as open enrollment gears up this week.
As enrollment surges, plans are facing increased scrutiny over risk adjustment practices, with regulators turning up the heat on payments in the program. Plus, star ratings are set to decline this year as new flexibilities introduced under the pandemic are removed and insurers are tasked with incorporating health equity into their ratings.
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Recent reports from federal watchdogs and experts have raised scrutiny over practices surrounding risk adjustment—which alters payments to plans based on patient health—namely that some plans are being overpaid by Medicare thanks to up-coding, a practice where plans add unnecessary diagnoses to codes to inflate risk scores of a patient. The higher the risk score, the higher the payment to the plan.
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“Health plans have responded and so have their vendors to develop new analytics to look for suspects that may be inappropriately coded as much as under-coded,” he said.
While plans are making changes to their current operations, that may not show up for a couple of years in audits conducted by HHS’ Office of Inspector General, Rogers said. “I think that’s going to take some time for that to really come through in these reviews and these reports.”
However, that doesn’t mean the Centers for Medicare & Medicaid Services (CMS) is going to leave risk adjustment alone. The agency released a request for information seeking comments on how to improve the MA program earlier this year.
