Market Institute President Charles Sauer writes in the Boston Herald that Massachusetts has an opportunity to lead the fight against fraud, waste, and abuse in Medicare Advantage by addressing the incentives that encourage insurers to inflate patient diagnoses and collect higher government reimbursements.
Medicare Advantage now serves roughly 35 million Americans, including 385,000 Massachusetts residents. But Sauer warns that the program’s success is threatened by “upcoding”—practices that can increase government payments by making patients appear sicker than they are. Estimates cited by Sauer put the potential cost as high as $1.3 trillion over the next decade.
“Diagnosis should be determined by medical professionals treating patients, not insurer billing departments,” Sauer writes. “Instead, risk adjustment has turned into a profit-centered strategy, not a patient-centered one.”
Sauer argues that policymakers should address the underlying incentives rather than simply pursue fraud after it occurs. He points to the No UPCODE Act as one potential solution, which would strengthen oversight of Medicare Advantage risk adjustment and prohibit unsupported diagnoses from being used to increase payments.
“The good news is that these problems are fixable,” Sauer concludes. “Massachusetts has an opportunity to lead by supporting reforms that eliminate upcoding incentives, strengthen accountability, and restore confidence in a program that hundreds of thousands of Bay Staters depend on.”
Read Charles Sauer’s full column in the Boston Herald.
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