Let’s focus more on caring, rather than coding

KevinMD November 16, 2022
Jay Anders, MD

Risk adjustment is a statistical method used by health plans to predict an individual’s use of health care services and the associated cost of care. Unlike traditional fee-for-service Medicare, Medicare Advantage (MA) plans receive a flat monthly payment for the individual beneficiary’s cost of care, with payments partially based on risk score.

Higher risk scores mean higher payments, and plans have financial incentives linked to more thorough documentation (coding) of their beneficiaries’ diagnoses. This “coding intensity” has escalated to the point where CMS now imposes a 5.9 percent reduction to MA risk scores to counter the effect. And the Medicare Payment Advisory Commission is pushing to rein in excess payments to MA plans.

Meanwhile, the Department of Justice is paying...

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