Upcharging and additional Diagnoses. About time this abuse was stopped.

Regulators crack down on Medicare Advantage charges
The Centers for Medicare and Medicaid Services (CMS) has finalized plans to reduce overpayments to Medicare Advantage insurers after a monthslong lobbying campaign from the industry opposing the changes.



Under the complex changes, set to roll out over the course of the next three years, CMS will enact what it calls “commonsense updates” to its payment model.



This will include transitioning to using diagnosis codes that align with the rest of the health care system and implementing new data, which the agency says is more accurate at predicting health care costs.



CMS pays private contracted insurers, known as Medicare Advantage Organizations (MAO), to provide Medicare services to their customers. These groups receive a set rate per beneficiary every year based on how likely they are to use health care services.



The more diagnoses a patient has, the higher the risk is assumed and the higher the payments to the organization for that individual.



MAOs have been criticized in the past for “upcoding” their patients, making them seem sicker on paper than they actually are by obtaining more diagnoses of conditions and thus more payments from the federal government.



CMS will be removing 2,000 diagnosis codes, which the agency says are no longer related to conditions for which Medicare costs can be predicted.



The health insurance industry has lobbied against these changes, running ad campaigns claiming the federal government is cutting Medicare funding.



Federal contracts account for large portions of these companies’ revenue and the proposed changes represent billions in reduced payments.

 
Welcome to The Hill’s Health Care newsletter, we’re Nathaniel Weixel and Joseph Choi — every week we follow the latest moves on how Washington impacts your health.

 


How policy will be impacting the health care sector this week and beyond:

 
Inflation helped drive up ObamaCare premiums this year

Monthly ObamaCare premiums rose in 2023 for the first time since 2019, driven by inflation and increased health spending, according to a new analysis. Despite continued growth in the number of insurers offering plans, the monthly premiums for Affordable Care Act (ACA) benchmark plans increased by an average 3.4 percent between 2022 and 2023, according to the analysis by the Urban Institute and Robert Wood Johnson Foundation. …



link; https://thehill.com/newsletter...e-advantage-charges/