Medicare Advantage Chart Reviews Are Associated With Billions in Additional Payments for Some Plans.

ABSTRACT:

Background

In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees' number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments. Recently the Government Accountability Office released a report raising concerns about the use of these chart reviews as a potential tool for upcoding.

Objectives

To measure the extent to which plans receive additional payments for chart reviews, and the variation in chart reviews across plans.

Research design

In this cross-sectional study we use 2015 MA Encounter data to calculate how many additional diagnoses codes were added for each enrolle

SUBMITTER: Meyers DJ 

PROVIDER: S-EPMC7855237 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature