AJMC February 24, 2025
These findings support the claim that Medicare Advantage (MA) payments may be driven more by diagnosis and coding practices rather than differences in disease burden between MA and fee-for-service (FFS) Medicare beneficiaries.
The similar prevalence of 4 out of 5 chronic conditions analyzed among Medicare Advantage (MA) and fee-for-service (FFS) Medicare beneficiaries suggests that differences in diagnosis and coding practices, rather than disparities in disease burden, may be driving higher payments to MA plans, according to a study published in the Annals of Internal Medicine.1
MA plans receive a monthly capitated fee based on beneficiaries’ risk scores, which CMS adjusts to account for underlying medical complexity2; this discourages plans from enrolling only the healthiest people. These plans have received widespread...
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