What's Happening?
The Alliance of Community Health Plans (ACHP) has released a report highlighting disparities in risk scores between major national Medicare Advantage (MA) insurers and community-based health plans. The report indicates that UnitedHealthcare and Humana have significantly higher risk scores compared to ACHP members, suggesting potential exploitation of the system. ACHP argues that these discrepancies are not due to a sicker patient population but rather due to system gaming, which impacts taxpayers and seniors. The organization is advocating for a streamlined risk adjustment process to reduce opportunities for gaming and improve equity in the system.
Why It's Important?
The findings from ACHP's report underscore ongoing concerns about upcoding in the Medicare Advantage program, which can lead to increased costs for taxpayers and reduced funds for patient care. By addressing these disparities, ACHP aims to ensure that resources are allocated more fairly and effectively, potentially leading to better healthcare outcomes for seniors. The proposed changes could also influence how risk adjustment is managed across the industry, prompting other insurers to adopt more transparent practices.
What's Next?
ACHP has engaged in discussions with the Centers for Medicare & Medicaid Services (CMS) regarding their proposals, which have been met with positive feedback. The organization plans to continue advocating for changes to the risk adjustment model, including reducing the number of condition categories to simplify the process. This could lead to more targeted audits and improved oversight of MA insurers, potentially reshaping the landscape of Medicare Advantage.
