To pay insurers, CMS uses a process called “risk adjustment” to estimate how sick patients are. Differences in diagnostic coding resulted in risk scores for MA beneficiaries that were higher than those for Medicare Fee-for-Service beneficiaries. The report says if CMS does not alter these risk adjustment methods, the amount of overpayments will likely exceed $3.1 billion in 2011 and 2012 and continue to grow.
The GAO said CMS could improve its process by accounting for additional beneficiary characteristics with the most current data available and being more mindful of the trend of coding differences when performing risk adjustment methods.
Related Articles on Medicare Overpayments:
Medicare Overpays 50 Teaching Hospitals for Double-Counted Residents
OIG Identifies Medicare Overpayments to 2 California Hospitals
Boston Medical Center to Refund $90K in Medicare Overpayments
At the Becker's 11th Annual IT + Revenue Cycle Conference: The Future of AI & Digital Health, taking place September 14–17 in Chicago, healthcare executives and digital leaders from across the country will come together to explore how AI, interoperability, cybersecurity, and revenue cycle innovation are transforming care delivery, strengthening financial performance, and driving the next era of digital health. Apply for complimentary registration now.
