In-Home Health Risk Assessments And Chart Reviews Contribute To Coding Intensity In Medicare Advantage

Area of Science:

• Health Economics
• Medicare Policy
• Healthcare Management

Background:

• Taxpayer costs are higher for Medicare Advantage (MA) plans compared to traditional Medicare.
• MA plans receive payments based on submitted diagnoses, creating an incentive for comprehensive diagnosis reporting.
• MA plans utilize in-home health risk assessments and chart reviews to identify additional diagnoses.

Purpose of the Study:

• To quantify the impact of in-home health risk assessments and chart reviews on MA payment-related risk scores.
• To analyze the effect of these diagnostic tools on overall MA plan payments.

Main Methods:

• Utilized Medicare Advantage encounter data from 2015-2020.
• Isolated the influence of in-home assessments and chart reviews on risk scores.
• Calculated risk score changes for payment years 2016-2021.

Main Results:

• Encounter-based risk scores for MA enrollees increased by 0.091 points.
• This represents a 7.4% increase in risk scores attributable to these assessment tools.
• The inclusion of in-home health risk assessments and chart reviews demonstrably inflated risk scores.

Conclusions:

• In-home health risk assessments and chart reviews significantly increase Medicare Advantage risk scores.
• These MA plan practices contribute to higher overall payments and taxpayer costs.
• Further investigation into the cost-effectiveness and equity of these diagnostic methods is warranted.