CMS Unveils Revised Medicare Advantage Risk Model to Combat Upcoding

The Centers for Medicare and Medicaid Services (CMS) has unveiled a revised risk adjustment model for Medicare Advantage plans, targeting the prevalent issue of upcoding by insurers. By utilizing 2018 data to calculate risk scores, CMS aims to improve patient health risk assessments while curbing insurers' abilities to inflate diagnoses for increased reimbursements. This strategic move is designed to align payments more closely with actual patient health needs, thereby enhancing regulatory compliance and efficiency.

In an effort to deter insurance providers from exploiting coding inconsistencies, CMS's updated model emphasizes accurate data integration and risk management. This initiative serves as a proactive measure to maintain the integrity and effectiveness of federal healthcare resources. By addressing potential discrepancies in payer and provider interactions, CMS is committed to minimizing unwarranted spending within the Medicare Advantage framework and fortifying the industry's underwriting and claims processes.