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Diane Publishing Books
Medicare Advantage: Substantial Excess Payments Underscore Need for CMS to Improve Accuracy of Risk Score Adjustments
James Cosgrove (au)
The Centers for Medicare & Medicaid Services (CMS) pays plans in Medicare Advantage (MA) -- the private plan alternative to Medicare fee-for-service (FFS) -- a predetermined amount per beneficiary adjusted for health status. To make this adjustment, CMS calculates a risk score, a relative measure of expected health care for each beneficiary. Risk scores should be the same among all beneficiaries with the same health conditions and demographic characteristics. Differences in diagnostic coding between MA plans and Medicare FFS led to inappropriately high MA risk scores and payments to MA plans, and CMS adjusted for coding differences in 2010. This report (1) determined the extent to which differences, if any, in diagnostic coding between MA plans and Medicare FFS affected MA risk scores and payments to MA plans in 2010, 2011, and 2012; and (2) identified what changes, if any, CMS intends to make to its risk score adjustment methodology for 2013 and future years. Table and figures. This is a print on demand report.
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