Chart Reviews Boost Medicare Advantage Payments
- Here's a breakdown of the key data from the provided text, focusing on the issues surrounding chart reviews in Medicare Advantage plans:
- * Medicare Advantage insurers are being investigated (and in some cases, sued) by the Department of Justice for perhaps fraudulent practices related to chart reviews.
- * Variation in Chart Review Rates: The percentage of enrollees who have had a chart review varies significantly between insurers.
Here’s a breakdown of the key data from the provided text, focusing on the issues surrounding chart reviews in Medicare Advantage plans:
The Core Problem:
* Medicare Advantage insurers are being investigated (and in some cases, sued) by the Department of Justice for perhaps fraudulent practices related to chart reviews.
* The allegation is that insurers are adding diagnoses to patient charts to increase their risk adjustment payments from CMS (centers for Medicare & Medicaid Services).
* Though,they are not consistently removing diagnoses that are found to be invalid during the same chart review process. This leads to unjustified payments from Medicare.
Key Findings from the Data:
* Variation in Chart Review Rates: The percentage of enrollees who have had a chart review varies significantly between insurers.
* High rates: CVS Health (86%), Elevance Health (82%), UnitedHealthcare (77%), Centene (73%)
* Low rates: Humana (34%), Kaiser Permanente (27%)
* More Diagnoses Added Than Removed: Across all major insurers, a larger proportion of enrollees had diagnoses added during chart reviews than had diagnoses removed.
* Centene (26%) and UnitedHealth Group (23%) had the highest percentage of enrollees with added diagnoses.
* Humana (9%) and Kaiser Permanente (4%) had the lowest.
* UnitedHealthcare’s Impact: While not the most likely to add diagnoses, UnitedHealthcare has the largest market share (nearly 30% of all Medicare Advantage beneficiaries) and therefore likely contributes the most to overall increased spending due to chart reviews.
Possible Explanations for the Differences:
* Different Approaches to Data Collection: Some insurers use health risk assessments (HRAs) and offer incentives for completion.
* Investment in Tools & Processes: insurers may have varying capacities to invest in chart review technology and personnel.
* Targeted Reviews: some insurers may focus chart reviews on specific populations or conditions.
In essence, the text highlights a potential issue of upcoding (increasing risk scores by adding diagnoses) within the Medicare Advantage system, and suggests that chart reviews, while intended for accuracy, might potentially be exploited to inflate payments.