A recent report from the HHS Office of the Inspector General (OIG) raises serious concerns about inappropriate Medicare Advantage denials of care as well as wrongful payment denials. It shows that Medicare Advantage plans, commercial health plans that contract with Medicare to deliver Medicare benefits, overturn their own denial decisions 75 percent of the time. Unfortunately, most […]

In most US health insurance markets, plans face strong incentives to “upcode” the patient diagnoses they report to the regulator, as these affect the risk-adjusted payments plans receive. We show that enrollees in private Medicare plans generate 6% to 16% higher diagnosis-based risk scores than they would under fee-for-service Medicare, where diagnoses do not affect […]

Each year, the Commission provides a status report on the Medicare Advantage (MA) program. In 2017, the MA program included almost 3,300 plan options offered by 185 organizations, enrolled about 19 million beneficiaries (32 percent of all Medicare beneficiaries), and paid MA plans about $210 billion (not including Part D drug plan payments). To monitor […]

Over the past decade, the average risk score for Medicare Advantage (MA) enrollees has risen steadily relative to that for fee-for-service Medicare beneficiaries, by approximately 1.5 percent per year. The Centers for Medicare and Medicaid Services (CMS) uses patient demographic and diagnostic information to calculate a risk score for each beneficiary, and these risk scores are […]

Risk adjustment’s role in federal health policy has become increasingly important. As a recent example, the Affordable Care Act (ACA) introduced health care Marketplaces where plan revenues are adjusted for the risk that higher cost enrollees may disproportionately join certain plans. Risk adjustment in the ACA Marketplaces builds on more than a decade of work […]