- Medicare Advantage plans may have received higher payments as a result of upcoding from 2010 to 2014, according to new research published by Health Management, Policy & Innovation. The study's authors, both from the University of Minnesota, point to overstated risk differences between MA and traditional fee-for-service populations they say are the result of upcoding within the risk adjustment system.
- Diagnostic intensity was more severe for patients with MA plans over that period of time. For example, patients with MA plans were diagnosed with diabetes at almost twice the rate of their peers in traditional fee-for-service plans.
- The authors argue that risk scores based on ICD-10 codes, a practice adopted in 2015, may have addressed this issue, but recommend CMS repeat their analysis. "Hopefully, ICD-10 is less susceptible to differences in coding intensity designed to take undue advantage of the government payment incentives," they write.
MA plans have been a boon for private insurers. That success has drawn the attention of watchdog agencies and researchers in the past. Previous studies have found risk scores of those who switched to MA grew faster than those who stayed in FFS, with MA enrollment growth intensifying those scores.
In 2016, Risk Adjustment Data Validation audits on MA plans found nearly all audited plans overcharged the federal government for most of their members.
Greater coding intensity could be an indication of upcoding, according to authors of this most recent study. Their results suggest MA plans may be using greater code intensity to drive higher risk scores. In order for upcoding to be ruled out, risk scores between MA and FFS populations would have to be closely parallel.
"This was not the case," they write.
CMS' 2014 overpayment rule attempted to tackle fraud and upcoding by requiring MA plans to report and reimburse overpayments within 60 days of identifying them. That rule allowed CMS to treat failures to return overpayments as violations of the False Claims Act. That led UnitedHealthcare, which had been sued under the new rule, to file a lawsuit against CMS in January 2016.
Much of the original lawsuit against UnitedHealthcare was tossed by the DOJ in 2018.