Credit: Pablo Martinez Monsivais/AP
The Wall Street Journal has added to the pressure on Medicare Advantage plan issuers by publishing its own analysis of how the issuers score their enrollees' health.
The Medicare Advantage program gives private insurers a chance to use a combination of Medicare program money and some premium payments from enrollees to provide an alternative to traditional Medicare. The program now covers 34 million of the 66 million enrollees.
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The issuers are supposed to use a standardized "hierarchical condition category" coding system to rate enrollees' health. Plans can get more cash from the federal government to cover sicker enrollees.
The Centers for Medicare and Medicaid Services, the agency that oversees Medicare, has been clashing with the issuers in recent years over allegations that some plans have been using aggressive risk-scoring practices to make enrollees look sicker than they really are.
Now Wall Street Journal reporters have obtained billions of anonymized claim records, conducted their own analysis and concluded that plans have coded enrollees aggressively enough that, over a three-year period ending in 2021, they received $50 billion in extra government payments for conditions that showed up in the risk scoring but that did not actually show up in the paid claims totals.
The federal government paid the plans more than $400 billion in 2023, according to the Medicare trustees' report. If the reporters are correct, the overbilling they say they detected could have amounted to about 3% of the payments.
The reporters contend that more than a dozen experts they consulted endorsed their methodology.
The insurers told the reporters that their patient record reviewers can often detect problems that patients' own physicians may not have diagnosed or treated.
The article appeared as CMS is continuing its own battles with insurers over risk scores; CMS is adopting 2025 reimbursement level that Medicare Advantage plan issuers have argued are too low; and critics are accusing plans of using unfair and burdensome strategies to determine whether they will pay for certain types of care, through prior authorization programs, and for deciding whether to pay for care that patients have already received.
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Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
