Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Upcoding in Medicare Advantage: Transparency can clean the mess

Trudy Lieberman
Policy
September 3, 2014
100 Shares
Share
Tweet
Share

That the government overpays sellers of Medicare Advantage plans is well known in Beltway circles even if much of the public remains unaware. Recently, two Department of Health and Human Services (HHS) researchers posted new findings on the Medicare and Medicaid Research Review, a peer-reviewed online journal supported by the Centers for Medicare and Medicaid Services (CMS), documenting how some insurance companies are overbilling the government and have been doing so for years.

Fred Schulte, a senior writer for the Center for Public Integrity who has been covering overbilling in the Medicare Advantage program, told me he spotted the new study while he was just cruising around the CMS website. “Despite its broad implications for Medicare spending, the study by HHS researchers Richard Kronick and W. Pete Welch has attracted scant notice in Washington,” Schulte wrote.

The Medicare Advantage program, which is growing rapidly, costs the government some $160 billion a year, so waste in the program can add up to real money. Recall that Medicare Advantage plans were promoted as a way for private insurers to provide the basic Medicare benefits and to save the government money by providing care coordination, especially for seniors with multiple chronic conditions. Generous payments from the government have allowed insurers to offer low- or no-premium plans and lots of extras, like dental care and eyeglasses, which help account for their popularity. About 16 million seniors are enrolled in a Medicare Advantage plan, almost one-third of all Medicare beneficiaries.

In June, the Center for Public Integrity published the results of its investigation showing that billions of tax dollars are misspent each year because of billing errors linked to payment tools called risk scores, which are at the heart of the recently published HHS study. In order to prevent Medicare Advantage health plans from trying to avoid covering high-risk participants, Medicare has been using a payment scheme based on diagnostic codes and adjusting payments to the plans accordingly. Health plans get more money for beneficiaries who need more care.

But as the General Accounting Office has pointed out, this payment method designed to solve one problem has simply created another: Medicare Advantage plans have learned to game the system to pad their reimbursements, a process called upcoding. That’s hardly surprising given the history of fraud and other unsavory practices in the program on the part of providers and insurers.

The HHS researchers found unexpectedly high risk scores for Medicare Advantage beneficiaries for conditions such as alcohol and drug dependence, complications of diabetes, and depression. For example, they found that drug and alcohol dependence is as much as eight times more common in the Medicare Advantage health plans that upcode the most than it was among beneficiaries who remained in traditional Medicare. The researchers also concluded that people who join Medicare Advantage plans are generally healthier than those who remain in the traditional fee-for-service program.

Will the HHS researchers’ study be a wake-up call for CMS and the Obama administration to finally crack down on the overpayments to Medicare Advantage plans? Remember, that was something the president vowed to do when he was campaigning for office. But in the last two years, each time the agency proposed cutting payments to Medicare Advantage plans, lobbying campaigns by the industry won out and those proposed cuts turned into payment increases.

Maybe there’s another route to cleaning up this mess: transparency. The researchers did not name the companies noted for upcoding the health risks and conditions of beneficiaries, but suggest that these are insurers with lots of Medicare customers. One of the highest billers had more than 200,000 policyholders. There’s always a chance public shame will help do the trick.

Trudy Lieberman is a journalist and an adjunct associate professor of public health, Hunter College, New York, NY. She blogs on the Prepared Patient blog.

Prev

Set free: Thank you for the freedom to care for this sick patient

September 3, 2014 Kevin 3
…
Next

Ebola in the United States: A reason not to panic

September 3, 2014 Kevin 1
…

Tagged as: Medicare

Post navigation

< Previous Post
Set free: Thank you for the freedom to care for this sick patient
Next Post >
Ebola in the United States: A reason not to panic

More by Trudy Lieberman

  • Health care’s future: An interview with a hospital CEO

    Trudy Lieberman
  • How to choose a good hospital? Hint: Don’t listen to the ads.

    Trudy Lieberman
  • a desk with keyboard and ipad with the kevinmd logo

    Yes, we do ration health care in America

    Trudy Lieberman

More in Policy

  • Why the WHO’s pandemic accord is critical for global health care

    Elizabeth Métraux
  • The revolutionary Kaiser-Geisinger deal: How health care giants are reshaping the industry and empowering patients

    Robert Pearl, MD
  • Unveiling the intricate link between housing costs and health care

    Harvey Castro, MD, MBA
  • Uncovering the truth about racial health inequities in America: a book review

    John Paul Mikhaiel, MD
  • Why affirmative action is crucial for health equity and social justice in medicine

    Katrina Gipson, MD, MPH
  • The untold story of Hispanic/Latino health: Why subgroup data matters

    Matthew B. Alonso
  • Most Popular

  • Past Week

    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

      Althea Halchuck, EJD | Conditions
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
  • Recent Posts

    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
    • Healing trauma and reconnecting: Unmasking the impact of dissociation [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why the WHO’s pandemic accord is critical for global health care

      Elizabeth Métraux | Policy

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 14 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • What Was Tied to Lower Long COVID Risk?
  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test
  • Pricey Drug Combo Boosts PFS in First-Line Advanced Ovarian Cancer

Meeting Coverage

  • Chemo-Free Approach Works in Subset of Patients With HER2+ Early Breast Cancer
  • Two-Drug Combo Wins for Refractory Gout
  • First-in-Class Sjogren's Drug Passes Mid-Stage Test
  • Pricey Drug Combo Boosts PFS in First-Line Advanced Ovarian Cancer
  • Cardiovascular Risk Models Still Fall Short for Arthritis Patients
  • Most Popular

  • Past Week

    • Physician entrepreneurs offer hope for burned out doctors

      Cindy Rubin, MD | Physician
    • Why doctors aren’t to blame for the U.S. opioid crisis [PODCAST]

      The Podcast by KevinMD | Podcast
    • The power of coaching for physicians: transforming thoughts, changing lives

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Unlocking the secrets of cancer conferences: an end-of-life counselor’s journey among pharmaceutical giants

      Althea Halchuck, EJD | Conditions
    • We need a new Hippocratic Oath that puts patient autonomy first

      Jeffrey A. Singer, MD | Physician
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • It’s time to replace the 0 to 10 pain intensity scale with a better measure

      Mark Sullivan, MD and Jane Ballantyne, MD | Conditions
    • Breaking point: the 5 reasons American doctors are dreaming of walking away from medicine

      Amol Shrikhande, MD | Physician
    • Revolutionize your practice: the value-based care model that reduces physician burnout

      Chandravadan Patel, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
  • Recent Posts

    • Master time management with 7 productivity strategies for optimal results

      Farzana Hoque, MD | Physician
    • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

      Hoag Memorial Hospital Presbyterian | Conditions
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
    • Healing trauma and reconnecting: Unmasking the impact of dissociation [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why the WHO’s pandemic accord is critical for global health care

      Elizabeth Métraux | Policy

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Upcoding in Medicare Advantage: Transparency can clean the mess
14 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...