M.A. plans are already ripping off the government for an estimated $80bil./year. That's in addition to their agreed-upon fees! Now Trump unilaterally doubles their pay raise? I wonder how big his bribe was!
I’ve stayed away from the repeated calls and attempts by robo-callers to switch over to an MA plan. Knowing that privatization of Medicare could spell disaster. Thanks for bringing this to light!!
Just a clarification about risk adjustment: the purpose of risk adjustment is to ensure that the revenue is commensurate with the financial risks given the accurate assessment of the burden of illness. The risk adjustment factors are generated by the government formulas.
The physicians who see the patient (health plan member) make the decisions about which ICD-10 codes reflect the true picture of the patient’s health conditions. The problem with getting a totally accurate set of diagnoses is that most physicians don’t take the time to document in their charts and then identify the whole list of conditions that flow into their claims.
In many cases, the doctors have seen the patients late in the calendar year and see no reason to retell the whole story again in the next visit in the new calendar year.
For risk adjustment purposes, these diagnoses expire every December 31 and must be redocumented every year. Otherwise, these diagnoses drop off and are no longer counted in calibration of the premiums. If they drop off but the patient still is being cared for regarding these diagnoses, the risk adjustment model assumes that these diagnoses are no longer valid. However, the health plan is still financially at risk for those conditions and the costs associated with taking care of the patient.
Even if a health condition is well managed, the physician still keeps the condition in mind when considering the whole treatment of the patient. Take diabetes, for example. If the patient is taking medication for diabetes and nothing else needs to happen to manage it, the presence of diabetes factors into the patient’s treatment for other conditions as well.
The abuse of the risk adjustment program comes into play when another physician adds conditions that are not currently being treated or managed by the original doctor. Also, overstating the severity of the condition or comorbidities is another abuse.
These tactics artificially inflate the risk scores by fudging the diagnoses. The Risk Adjustment Data Validation (RADV) audit is used to sample the data records and the medical records to identify any suspected exaggeration of the patient’s diagnoses. This is where errors, inadvertent errors or intentional errors, are identified. The errors that do not appear to be fraudulent but are inadvertent (no systematic errors suggesting intentional fraud) are then extrapolated across the entire membership in the 201 selected in the sample with the same health conditions, and a financial penalty is imposed on the health plan.
Fraud is elevated to the OIG for prosecution under the False Claims Act which carries extreme penalties.
M.A. plans are already ripping off the government for an estimated $80bil./year. That's in addition to their agreed-upon fees! Now Trump unilaterally doubles their pay raise? I wonder how big his bribe was!
I’ve stayed away from the repeated calls and attempts by robo-callers to switch over to an MA plan. Knowing that privatization of Medicare could spell disaster. Thanks for bringing this to light!!
Just a clarification about risk adjustment: the purpose of risk adjustment is to ensure that the revenue is commensurate with the financial risks given the accurate assessment of the burden of illness. The risk adjustment factors are generated by the government formulas.
The physicians who see the patient (health plan member) make the decisions about which ICD-10 codes reflect the true picture of the patient’s health conditions. The problem with getting a totally accurate set of diagnoses is that most physicians don’t take the time to document in their charts and then identify the whole list of conditions that flow into their claims.
In many cases, the doctors have seen the patients late in the calendar year and see no reason to retell the whole story again in the next visit in the new calendar year.
For risk adjustment purposes, these diagnoses expire every December 31 and must be redocumented every year. Otherwise, these diagnoses drop off and are no longer counted in calibration of the premiums. If they drop off but the patient still is being cared for regarding these diagnoses, the risk adjustment model assumes that these diagnoses are no longer valid. However, the health plan is still financially at risk for those conditions and the costs associated with taking care of the patient.
Even if a health condition is well managed, the physician still keeps the condition in mind when considering the whole treatment of the patient. Take diabetes, for example. If the patient is taking medication for diabetes and nothing else needs to happen to manage it, the presence of diabetes factors into the patient’s treatment for other conditions as well.
The abuse of the risk adjustment program comes into play when another physician adds conditions that are not currently being treated or managed by the original doctor. Also, overstating the severity of the condition or comorbidities is another abuse.
These tactics artificially inflate the risk scores by fudging the diagnoses. The Risk Adjustment Data Validation (RADV) audit is used to sample the data records and the medical records to identify any suspected exaggeration of the patient’s diagnoses. This is where errors, inadvertent errors or intentional errors, are identified. The errors that do not appear to be fraudulent but are inadvertent (no systematic errors suggesting intentional fraud) are then extrapolated across the entire membership in the 201 selected in the sample with the same health conditions, and a financial penalty is imposed on the health plan.
Fraud is elevated to the OIG for prosecution under the False Claims Act which carries extreme penalties.
Disgraceful.