Open AccessMedicare Advantage Chart Reviews Are Associated With Billions in Additional Payments for Some Plans
Author(s) -
David J. Meyers,
Amal N. Trivedi
Publication year - 2020
Publication title -
medical care
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.632
H-Index - 178
eISSN - 1537-1948
pISSN - 0025-7079
DOI - 10.1097/mlr.0000000000001412
Subject(s) - chart , reimbursement , payment , actuarial science , business , government (linguistics) , medicine , operations management , health care , statistics , finance , economics , mathematics , linguistics , philosophy , economic growth
In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees' number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments. Recently the Government Accountability Office released a report raising concerns about the use of these chart reviews as a potential tool for upcoding.