Coding Intensity Through Health Risk Assessments and Chart Reviews in Medicare Advantage: Does It Explain Resource Use?

Abstract

Medicare Advantage (MA) plans increase their risk-adjusted payments through intensive coding in health risk assessments (HRAs) and chart reviews. Whether the additional diagnoses from HRAs and chart reviews are associated with increased resource use is not known. Using national MA encounter data (2016–2019), we examine the relative contributions of three health risk scores to MA resource use: the base risk score that excludes diagnoses from HRAs and chart reviews; the incremental score added to the base score from diagnoses in HRAs; and the incremental score added from diagnoses in chart reviews. We find that the incremental risk scores explain 53.4%-63.9% of resource use relative to the base risk score effect—that is, 36.1% to 46.6% of the incremental risk scores are not accompanied by increased resource use. While HRAs and chart reviews contribute to more complete coding of diagnoses, they are sources of intensive coding not accompanied by resource use.

Keywords

Medicare advantage coding intensity chart reviews health risk assessments

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References

Abelson

Sanger-Katz

(2022). ‘The Cash Monster Was Insatiable’: How insurers exploited Medicare for billions. The New York Times. https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html

Centers for Medicare and Medicaid Services. (2017). Medicare Advantage risk adjustment data validation audits fact sheet. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-Risk-Adjustment-Data-Validation-Program/Other-Content-Types/RADV-Docs/RADV-Fact-Sheet-2013.pdf

Centers for Medicare and Medicaid Services. (n.d.). Risk adjustment. https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors

Congressional Budget Office. (2022, May). May Congressional Budget Office (CBO) Medicare baseline for 2022. https://www.cbo.gov/system/files/2022-05/51302-2022-05-medicare.pdf

Freidin Brown

P. A

. (2018). Freidin Brown, P.A. attorneys secure $7 million result in whistleblower case. https://www.prnewswire.com/news-releases/freidin-brown-pa-attorneys-secure-7-million-result-in-whistleblower-case-300753286.html

Frogner

B. K.

Anderson

G. F.

Cohen

R. A.

Abrams

(2011). Incorporating new research into Medicare risk adjustment. Medical Care, 49(3), 295–300.

Jung

Carlin

Feldman

(2022). Measuring resource use in Medicare Advantage using encounter data. Health Services Research, 57(1), 172–181.

Jung

Carlin

Feldman

Tran

(2022). Implementation of resource use measures in Medicare Advantage. Health Services Research, 57(4), 957–962.

Medicare Payment Advisory Commission. (2019). June 2019 report to the congress: Medicare and the health care delivery system. https://www.medpac.gov/document/http-www-medpac-gov-docs-default-source-reports-jun19_medpac_reporttocongress_sec-pdf/

10.

Medicare Payment Advisory Commission. (2023). March 2023 report to the congress: Medicare payment policy. https://www.medpac.gov/document/march-2023-report-to-the-congress-medicare-payment-policy/

11.

Meyers

D. J.

Trivedi

A. N.

(2021). Medicare Advantage chart reviews are associated with billions in additional payments for some plans. Medical Care, 59(2), 96–100.

12.

Newhouse

J. P.

(2021). Commentary on: The effects of coding intensity in Medicare Advantage on plan benefits and finances. Health Services Research, 56(2), 175–177.

13.

Office of Inspector General. (2019). Billions in estimated Medicare Advantage payments from chart reviews raise concerns (OEI-03-17-00470). U.S. Department of Health and Human Services.

14.

Office of Inspector General. (2020). Billions in estimated Medicare Advantage payments from diagnoses reported only on health risk assessments raise concerns (OEI-03-17-00471). U.S. Department of Health and Human Services.

15.

Office of Inspector General. (2021). Some Medicare Advantage companies leveraged chart reviews and health risk assessments to disproportionately drive payments (OEI-03-17-00474). U.S. Department of Health and Human Services.

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