Modern Healthcare

By: Shelby Livingston

A federal judge’s recent decision to vacate a 2014 CMS rule that UnitedHealthcare said resulted in underpayment for Medicare Advantage insurers leaves the federal government with fewer tools to combat upcoding practices that cost the taxpayer-funded Medicare program billions of dollars.

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Edwin Park, research professor at Georgetown University’s Center for Children and Families, agreed that the ruling is “taking away a tool the CMS is using to ensure accurate documentation” and that “would mean likely higher payments.” He pointed out that Advantage insurers are profiting as enrollment in the plans grows steadily year over year. Payments to Medicare Advantage plans totaled $210 billion in 2017 to manage the care for 19 million seniors. Advantage insurers’ profits—their margins average between 4% and 5%, according to S&P Global—are helped by programs like retrospective chart reviews to comb patient medical records for additional diagnosis codes. “If you don’t have penalty on insurers to adequately ensure accurate documentation, you will have coding practices to distort payment going forward,” Park said.

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