By NextBestFitFix Medicare Advantage payments
Base risk adjustment on two years of data, exclude diagnoses from home visits and chart reviews, and audit plans.
Interim savings until Medicare Advantage is folded in.
Review ledgerHow this path connects
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Use two years of diagnosis data for risk scores
- Exclude diagnoses from home visits and chart reviews
- Expand RADV audits with extrapolated recoveries
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
- Medicare Advantage overpayments and coding intensity
Changing diagnosis sources and risk-adjustment data and auditing plans saves money while preserving plan choice and extra benefits. It retains the existing popular program.
- Losing the choice of health plan and insurer competition
Reforming payments while retaining private Medicare plans preserves plan choice and extra benefits.
- Dental, vision, and hearing are mostly uncovered
Plans may cut extra benefits as payments decline.
- Targets and quality metrics invite gaming
Plans adapt to coding reforms, and previous reforms only partly closed the payment gap.
Who's affected
- Taxpayers and public budgets
- Medicare Advantage overpayments and coding intensity: Aggressive diagnosis coding raises payments to private Medicare plans.
- Medicare beneficiaries
- Medicare Advantage overpayments and coding intensity: Overpayments increase their premiums.
- People with employer coverage
- Losing the choice of health plan and insurer competition: They can't keep or pick a plan they like, or switch if service is poor.
- Health insurers, brokers, and their shareholders
- Dental, vision, and hearing are mostly uncovered: Private Medicare plans market extra benefits missing from traditional coverage.
- Cash-pay and private care practices
- Dental, vision, and hearing are mostly uncovered: Coverage gaps support cash-pay care.
- Hospitals, clinics, and care organizations
- Targets and quality metrics invite gaming: They can benefit by changing referral dates, avoiding sick patients, or upcoding.
- Health insurers, brokers, and their shareholders
- Medicare Advantage overpayments and coding intensity: Plans receive larger payments when enrollees look sicker on paper.
- Health administration and software vendors
- Medicare Advantage overpayments and coding intensity: They provide risk-adjustment and coding services rewarded by larger payments.
- Older adults
- Dental, vision, and hearing are mostly uncovered: Coverage gaps and costs lead them to skip dental and other excluded care.
- Low- and middle-income households
- Dental, vision, and hearing are mostly uncovered: Coverage gaps and costs lead them to skip dental and other excluded care.
- People with ongoing or specialist care needs
- Targets and quality metrics invite gaming: Gaming wait-time and quality measures undermines their intended protection.
Where it has been tried
- MedPAC recommendations: MedPAC estimates billions of dollars in coding-intensity overpayments.