With all the major talk of risk-adjustment overpayments coming from numerous regulators, lawmakers, and MA detractors, MA plans should ready for changes to risk adjustment submissions.

 

About The Podcast:

Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.

 

Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.

 

Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.

 

Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through the Healthcare Labyrinth website and his book of the same name.

 

Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.

 

Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.

 

 

About The Episode:

 

On this episode, Marc discusses the Medicare Advantage rate-setting and risk adjustment process. With all the major talk of risk-adjustment overpayments coming from numerous regulators, lawmakers, and MA detractors, Marc says MA plans should ready for changes to risk adjustment submissions. He predicts that the use of Health Risk Assessment and manual chart reviews could be reined in or barred.

  

Key Takeaways:  

 

Rate-setting was rolled out by CMS to emphasize quality achievement and it has served Medicare Advantage plans well. It has led to generous supplemental benefits for enrollees compared with traditional Medicare.

 

Risk adjustment is important as it recognizes differences in risk of enrollees and helps ensure fair compensation for plans.

 

There are major criticism of MA plans for so-called overcoding and overpayments due to risk adjustment. Some of these accusations are unfounded, but some should have more scrutiny.

 

The use of health risk assessments and manual chart reviews are areas that should be looked at for abuse.

 

Due to concerns, CMS could rein in or bar the use of health risk assessments and manual chart review to supplement diagnoses submissions in risk adjustment.

 

MA plans should plan now for what the new world will look like.

 

 

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance