United Healthcare

[JimG454455]

Just curious when you guys are going to address and speak to this issue. My guess is many of your members are negatively affected by Advantage plans and more specifically the ones AARP endorses - United healthcare. I am currently living the nightmare of dealing with UHC. Their denial, delay and defend strategies have all been applied to my care which has had a significant negative impact to my care and recovery.  I joined AARP because of your advocacies for seniors. What is currently in the news about the horrors of our healthcare system that are affecting seniors most needs to be talked about.

The fact that AARP has been mostly silent on these matters AND endorses the worst offender is a disservice to your members. You lend your respected name, which I know your are paid handsomely for,  at the peril of your members.

The exposure and pressure to reform their cruel practices needs more coverage, not just a silent endorsement.

Please step up and help us on this issue.

Regards

Jim Groll

[GailL1]

@LisaS961881 

That Newsweek articles sound like a WHOLE lot of speculation - Is there a DOJ criminal case - they don’t know.

Is there a judge appointed - they don’t know.

Is the judge gonna make a decision on moving forward with the case from last year - again they don’t know.

[SusanM664094]

It's an ongoing situation. Apparently there's multiple investigations.

https://www.reuters.com/business/healthcare-pharmaceuticals/unitedhealth-shares-drop-after-report-cr...

[LisaS961881]

Thank you for sharing this link.

~ Lisa

[TRL1111]

It's based on an anonymous source, which is different from speculation.  

The original reporting comes from the Wall Street Journal (Newsweek and other news outlets are just repeating it), and the Wall Street Journal is who did the excellent reporting recently about Advantage plans upcoding to obtain bigger payments from the government for their Advantage enrollees.  

But all of them upcode, and in the article a Congressman is quoted as saying this about upcoding:  "It's not necessarily fraud because some of this is legal but they're pushing the boundaries, and it's really immoral in fact."

As with everything once you scratch the surface...it's complicated.

My question is why isn't the government investigating ALL of the Advantage plans?

[LisaS961881]

I appreciate your reply and agree with everything that you wrote.   Thank you for highlighting that specific quote.

[GailL1]

@TRL1111 

Doctors upcode - 

We can probably have a conversation on how a beneficairy should be rated as to their health risk under a Medicare Advantage plan.  

CMS has always been the government entity of setting the parameters - so maybe they just need to get on it.  

[TRL1111]

---

@GailL1 wrote:

Doctors upcode - 

---

I'm not sure what your point is, but yes, doctors upcode.  But the subject of the Wall Street Journal investigation was Advantage plans themselves upcoding their members to have diagnoses that their doctors haven't made.  They do this because the Advantage plan gets extra money from the government for each diagnosis its members have--the more diagnoses a member has, the more money the Advantage plan gets paid by the government for that member.  And apparently often the member's doctor doesn't find out it's happened, nor does the member.

Which is bad, but could be worse if the member tries to switch to traditional Medicare with a supplement and has to undergo medical underwriting, during which their medical condition is evaluated.

This upcoding is often done during the home visits that plans encourage members to agree to.  

Here's the WSJ article about the upcoding, and note that several companies are identified as doing it.

https://www.wsj.com/health/healthcare/medicare-health-insurance-diagnosis-payments-b4d99a5d?mod=RSSM... 

[GailL1]

@TRL1111 

Is that the one where they are questioning the use of AI in determining prior approvals?  I think it is Aetna, UHC and Cigna; maybe more - 

I posted an article that was dated back in March 2025 where the government case against UHC MA was dismissed concerning their risk adjustments.  

KFFHealth News 03/04/2025 - UnitedHealth Wins Ruling Over $2B in Alleged Medicare Advantage Overpaym... 

I have not heard that any new charges have been filed for risk adjustment against them.  

What is the case about that you and others are talking about here - I do not have access to the WSJ for free.  From the other links that have been reported here - they don’t say much.  

[TRL1111]

---

@GailL1 wrote:

Is that the one where they are questioning the use of AI in determining prior approvals?  I think it is Aetna, UHC and Cigna; maybe more - 

---

No.  As I said, it's an investigation into Advantage plans themselves upcoding their members to have diagnoses that their doctors haven't made, and for which the member receives no treatment, usually after a home visit where the Advantage representative asks a bunch of health questions.  They're called "insurer-driven diagnoses" in the article.

The Wall Street Journal really put the legwork into their investigation.  It was certainly eye-opening to me.

Did you actually try the WSJ link?  They're usually paywalled for me, but for some reason that one works.  Maybe it's a fluke.

Or you might this one; MSN.com sometimes posts WSJ articles without a paywall:

https://www.msn.com/en-us/health/other/insurers-pocketed-50-billion-from-medicare-for-diseases-no-do... 

I realize Advantage plans provide valuable coverage for people who can't afford a supplement, but they really are a snake pit, and every time I pay my supplement bill, I consider it a vote in favor of traditional Medicare and against Advantage plans.

[GailL1]

But that case has been dismissed - back in March 2025 and I have not hear of any new claim or any judge opening it it back up again.  It was dismissed on the grounds that it was not proven to be a bad concept or method since CMS has never laid down the rule as to how it should be done.

Then there is the case against (3) MA insurers with UHC being one that attempts to stop them from using AI to review medical records for prior approvals - What is wrong with that?  I would imagine that this is gonna be pretty commonplace in all types of health insurance - maybe other types of insurance as well.

Then there is the case of MA insurers sending medical aids out to a person’s home to evaluate them for all kinds of things from safety to nutrition of which adding a diagnosis+ code to their file may also be questioned.  But how can this be wrong when CMS has given some authority to do this sort of thing in their CMMI programs.  

CMS can set any sort of rules they want over MA plan insurers - they started some just this year on prior approvals - CMS can make the rules very strict on how to determine when a MA member can be risk rated up for additional payments.

The big reason why they don’t is they know that if they do, more MA insurers will leave the Medicare Part C program and even thought they are now saving them any money now - sending all these beneficiaries back to Traditional Medicare would be a disaster for Medicare, the program.  They may have to become managed care if that happened.  

[CBtoo]

Using AI: Research has documented that right now anyway, AI is ONLY good for simple, uncomplicated, one problem only, type of cases OR in the use with diagnosis when it has been trained on by zillions, for example, of mammograms with known results. It is pretty good at picking up  breast cancer in mammograms although it may miss other issues seen on them that radiologists know to flag. And yes there are some cases out there like that (eg simple ones). Many are not. Will AI improve over the years? Likely? Is it good enough to use today - likely not in many ways it is currently being used. And that, in my opinion, is the problem with using AI except for what it is already known to be good at.

Unfortunately insurance companies (not just medicare) has been using computers with automated systems to approve/reject referrals, approval for tests, claims, etc. for years. Been past lawsuits over that. Or using (which is just as bad in my opinion) RN's to make decisions on things they were never trained about in RN school with respect to rejecting or accepting referrals, approvals for tests, etc. Especially when the decision is made in 15 seconds or less (typically as some companies have quotas).

[GailL1]

@CBtoo  There are books and manuals from our government which can be used for coverage - like the CMS Medicare Coverage Determination - it is constantly under review for medical protocols, best practices, FDA approval of medical devices - this is where many insurance companies get their review techniques and information.

CMS.gov - Medicare Coverage - General Information 

There is one also for Medicare - Part D

This is the type of information that is fed into the AI memory - but in a way, you might be right because of the continuing question of whether medical care is a science or an art?

AI is gonna be around, getting better and better and being used more and more - we just have to make sure that we pay attention to the rule - “garbage in means garbage out” so that means to me that what is founded to be right at the current time is pretty conclusive and that changes continue to be made when science moves forward.  

[TRL1111]

---

@GailL1 wrote:

Then there is the case of MA insurers sending medical aids out to a person’s home to evaluate them for all kinds of things from safety to nutrition of which adding a diagnosis+ code to their file may also be questioned.  But how can this be wrong when CMS has given some authority to do this sort of thing in their CMMI programs.  

---

Did you read the article?  Here's how it can be "wrong":

==========================

Some diagnoses claimed by insurers were demonstrably false, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert.

“It’s anatomically impossible,” said Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham. “Once a lens is removed, the cataract never comes back.”

Another 36,000 diabetic cataract patients didn’t receive any medical services or prescription drugs related to diabetes.

===========================

[GailL1]

It is very rare, maybe never, that a person with diabetic eye disease ever gets cured.  

National Institute of Diabetes and Digestive and Kidney Diseases - Diabetic Eye Disease 

These insurers don’t or should not go into this half-baked.  They have or should have research behind them in their decision.  Diabetes can be far reaching in it’s affect on the body and with the eyes and the blood vessel changes in a diabetic person, the test and evaluations are ongoing.  

Having a diagnosis of diabetes with diabetic eye disease involvement in and of itself is a higher rating for a Medicare beneficiary whether under Traditional Medicare or a MA plan.  It also calls for the testing and the treatment to be done by a specialist - an Opthalmologist - which would added cost to this condition.  

A Medicare patient that is NOT diabetic can get these same preventive test annually from a lower cost professional - like an Optician licensed to do them.  If there is any problem noted the lower cost professional can refer them to the higher treating professional. 

Sure, there may be some who evaluate these beneficiaries towards the higher risk when they are not - but that happens because in some cases human’s are making the call on the extent of the condition.  Diabetes and its affect on the body can be very costly in the vast treatment areas.

All CMS has to do is set down some rules - but they seem not to  be able to do that - they do not want even the appearance that they are trying to control care - so they specifically have MA plans to do it.

State MEDICAID programs use risk based MCO’s to manage their MEDICAID programs in much the same way -

KFF.org - 10 Things To Know About MEDICAID Managed Care 

See #2

Nothing in government or their constant striving to save money is ever simple. I could write a whole lot more but will end with the fact that CMS could control this - they are already lowering the amount of paid to MA plans for service to their beneficiaries.  But they won’t because MA plans are important to the overall program.  

[TRL1111]

---

@GailL1 wrote:

It is very rare, maybe never, that a person with diabetic eye disease ever gets cured.  

---

Did you read the article the WSJ published about its investigation into insurer-driven diagnoses?

It's not just diabetic cataracts (which can't exist if a person has had cataract surgery), but other conditions that insurers diagnose but for which the person doesn't receive treatment.

[SusanM664094]

"how a beneficairy should be rated as to their health risk under a Medicare Advantage plan"

And why should this be done? What would be the reasoning? Could they opt out of signing up the sicker patient to be more profitable?

[GailL1]

---

@SusanM664094 wrote:

"how a beneficairy should be rated as to their health risk under a Medicare Advantage plan"

And why should this be done? What would be the reasoning? Could they opt out of signing up the sicker patient to be more profitable?

---

Really ?  I guess you don’t understand how Medicare and Medicare Advantage work together to cover the beneficiary.  

This is gonna be a VERY simplistic explanation: 

Medicare (or CMS) pays the Medicare Advantage plan basically a per beneficiary average health cost which they determine in the regular Medicare program.  This comes from both the Part A and Part B Trust Funds.

So just like in the regular program, there are some people who are sicker than others.  It is up to the Medicare Advantage plan to prove to CMS that some of the beneficiaries in their MA plan are sicker - they do this by a risk adjustment.  

When they do this - CMS pays them MORE than the average for these beneficiaries because they are costing them more or will cost them more than the average.

Now sometimes the MA insurer will search for different coding from the doctors indicating diagnosis codes or other treatment /test hints that the doc is looking for things more serious in order to get a jump on these patients before they start costing them too much before the CMS adjustment.  So the Medicare Advantage insurer will scrutinize their claims and diagnosis data for those that will or may cost them more.

Medicare Advantage plans are managed care meaning they have to make sure all protochols and best practices ae being used in the treatment of their member beneficiaries.  This is how MA plans hold down cost because they can ask for details and have things like prior approvals. Managed care is their methods of holding down cost (managed care is also used in MEDICAID too).  Traditional Medicare uses only paying a % of the cost that has been negotiated to hold down their cost with some prior approvals and stated coverage restrictions.

So NO, MA plans do not refuse any beneficiary - Medicare Advantage is a Part of Medicare - Medicare Part C.  They just want to be paid fairly - CMS does not go back and pay for any beneficiary that has chosen a MA plan - it is up to the MA plan to up their risk assessment of a beneficiary before they are paid more for that beneficiary.

This has been the routine since MA plans were invented in the early 2000 - but CMS really did not give any details as to what these plans could look for to add to this risk assessment money.

So thru the years, MA plans or at least some of them have been stretching the limits in proving these risk assessments.  Course, then there are the docs who also upcode their patients making them seems sicker than they maybe to be paid more money.

None of this would even be questioned if CMS had some hard and fast rules on when a patient could be rated higher risk - 

Medicare Advantage plans came about to save the Medicare system money - they did at 1st but now since they are being paid for many who are rated as higher risk, they aren’t saving money.  But they do still provide for a segment of the Medicare beneficiaries who cannot afford to pay for a lucrative Medigap plan - the ones that can handle the copays but not a monthly premium of several hundreds of dollars.

[LisaS961881]

Susan,

   Thank you for your insight.  
    I wanted to reply to your question -

    I was searching the DOJ website yesterday to determine if there were any new releases on that site concerning this topic.  I found none.  However, I did discover this release. .While it does not pertain to Upcoding, and these are merely allegations at this juncture, I wanted to share this link. Please note the first and second sentences of the third paragraph:

https://www.justice.gov/opa/pr/united-states-files-false-claims-act-complaint-against-three-national... 

…..and yes, “once you scratch the surface….its complicated”.

~ Lisa

[SusanM664094]

I'm sure more information will be coming out in the days to come on both types of investigations. 

[LisaS961881]

….and while I’m on vacation, I just had to take a moment to add this update to the previous conversations!

https://thehill.com/policy/healthcare/5418393-unitedhealth-doj-investigation-medicare-billing/

….still hopeful,

     ~ Lisa. 🛶 🏊 📚🌈🙏🙋🩵

[GailL1]

Old News is New News - there is certainly a lot of talk in the Washington town about this method of upcoding beneficiaries.  Several pieces of legislation have been introduced, CMS is in talks with the various large Medicare Advantage insurers on their practices.  

Plus,Medicare needs money so it seems they are pursuing this more now than in the past when I guess things just didn’t pan out for any corrections. 

CMS.gov - News Release 05/21/2025 - CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medi... 

Then there is also these risk adjustments audits that evidently had no action.

CMS.gov - Medicare Advantage Risk Adjustment Data Validation Program(last modified 07/21/2025) 

What gets me the most is why no action in past years?  

Do you think that our government has been lax about this because they don’t want to lose MA insurers - especially of the larger variety?

[Tonster521]

 @gail1 I found an article on the internet that provides an explanation of how each part of Medicare is funded. https://www.valuepenguin.com/medicare-funding#part-b Generally, I try to obtain the authors bio to make an educated guess if the author has any background in the subject. Sometimes, all you obtain is that an author has a journalism background and no direct experience. The bio for author, Jim Arvantes, indicates 20 years in the healthcare field with 7 years as the Washington Correspondent for the American Academy of Family Physicians(AAFP). So, I would say Jim is a creditable source. 

Anyway, we know that the Feds try to split the Parts B and D costs 75% and 25% with the Feds paying for 75%. I am sure that when you inform folks of that split, many are not aware. Some even believe when they contribute the $185 for Part B and $28 (average contribution) for Part D, they are paying the full costs. Maybe, using the word, "premium", causes the confusion. Folks may relate the word, "premium", with what they pay for other types of insurance such as life, auto, homeowners, etc. In any event, many folks do not know that they are receiving Federally subsidized healthcare insurance benefits (welfare benefits) called Medicare Parts B and D. So, the issue is how do you fund Medicare Advantage Plans which were established in 2003 (previously know as Medicare Choice from 1997)? It is complicated and well beyond most folk's comprehension and experience. In the simplest explanation that I can offer, the CMS developed a bid procedure for MA which establishes a base rate that varies by County and a risk adjusted rate that varies from person to person based on a review of their health. I do not know the exact protocols for the risk adjusted health review. However, I suspect that weight, blood pressure, pulse, oxygen (via Pulse/Ox device), range of motion, some memory questions, episodes of past illnesses, etc. labs, if available, are considered Essentially, information that a nurse generally obtains when you are at the doctor's office. However, many folks do not see a doctor until there is an acute health concern. Home visits by a registered nurse (RN) or an advanced practice registered nurse (APRN) have been the solution for MA. It is rare to find a doctor that does house calls. Remember, Parts B and D essentially have unlimited access to the U.S. Treasury General Fund. MA does not. So, MA has to get the risk adjustment right to obtain the funds necessary to provide benefits. 

In many articles, the word, upcoding, is used to convey that something questionable is being utilized to increase the risk adjustment component of the funding procedure. There may be findings obtained in CMS audits where that is the case and those cases need to be addressed. However, I suspect that with a 50% MA enrollment or about 30 million folks, there are probably cases that will be questioned by CMS. Maybe medical records are not complete or missing. I do not expect that auditors are going to challenge documented medical conditions. So, no matter what approach CMS uses to allocate money to fund MA Plans, folks are going to be "floored" by the amounts of money for about 30 million folks (6o million x 50%) enrolled with MA. For example, if the Federal money was simply based on a percentage basis, the $452 Billion for Part B would amount to $7,533 per person (50% X $452 Billion divided by 30 million folks). The Part D is more complicated because not every person enrolls in Part D, monthly contributions vary (if any), and MA Plans provide RX benefits to just about all enrolled (Close to100%). Nonetheless, I developed an allocation based on 73% of $105.8 Billion or $77.234 Billion. Using 30 Million Folks, I arrived at $2,574 per person with the assumption that there is no additional monthly contribution from the MA folks. That amount can be reduced with exact numbers rather than the best estimates that I used. In other words, the remaining 23% is a combination of Part D premiums (contributions) and State payments for dual coverage Medicare/Medicaid. So, that is about $10,000 per MA enrolled based on the percentage splits that I used. It is not an exact science. The 50%/50% approach would cause a shortfall to the MA Plans inasmuch as some folks may have greater morbidity. MA Plans do not have unlimited access to the U.S. Treasury General Fund wherein Parts B and D do. So, MA Plans need to obtain an allocation of Federal money appropriate for the medical risk they are accepting. Otherwise, MA Plans will fail financially which is not what the CMS wants to happen. The CMS audits should uncover a limited amount of cases that have been "upcoded" incorrectly. Perhaps there are other readers that may review my calculations and offer other approaches.

[TRL1111]

---

@Tonster521 wrote:

However, many folks do not see a doctor until there is an acute health concern. Home visits by a registered nurse (RN) or an advanced practice registered nurse (APRN) have been the solution for MA.

---

Somehow I managed to find the above in your wall of text.  If folks aren't seeing a doctor for a condition, then the Advantage plan isn't paying any bills because of it.  If the Advantage plan isn't shelling out any money for it, then why should the government be giving them more money because of it?

[Tonster521]

@TRL1111, As I understand MA, you need to select a primary care physician. If you do not schedule an initial patient/doctor visit (essentially routine visit), the MA Plan will continue to contact you to do so even offering a home visit. I understand that some MA Plans will provide an incentive to schedule a home visit. So, the MA Plans pursue either "face to face" approach/visit. I believe this is how an initial health evaluation is accomplished. This is when folks are diagnosed and follow up treatment is established. I am not aware of any doctor in a fee for service plan (i.e., Medicare Part B) that does this initial health evaluation. I believe Part B provides an annual wellness exam/visit. However, the person needs to request/schedule such exam.

[TRL1111]

---

@Tonster521 wrote:

---

I believe this is how an initial health evaluation is accomplished. This is when folks are diagnosed and follow up treatment is established.

---

If you read the WSJ investigation, you'll see that the people who were being upcoded already had doctors.  The Advantage insurance companies get their members' medical records from their doctors.  The doctors have already diagnosed people's conditions.

And you mentioned an annual wellness visit that's covered by Part B for people with traditional Medicare.  However, that's not a hands-on physical like most people are used to.  It's more of an interview and doesn't involve diagnosing conditions.  A lot of people are disappointed to find out that under traditional Medicare, if they want an annual check-up, they have to pay for it out of pocket.  Or worse, they don't find out until after their visit that when their doctor went outside the bounds of what's covered in an annual wellness visit into the realm of a physical like most people are used to getting, they're going to get a bill from the doctor because Medicare doesn't cover that.

[GailL1]

@Tonster521 There maybe some Medicare Advantage plans that do such services - perhaps those that are writing the Speical Needs MA plans.  But this is different - this is about the use of the Risk Adjustment methodology that some of the MA insurers have initiated to up their payments for those who are sicker.

CMS began implementing risk adjustment for Medicare Advantage (MA) plans in 2004. This marked a shift from a system that relied solely on demographic information to one that also considered the health status of enrollees when determining payments to MA plans. 

Here's a more detailed breakdown:

• Initial Implementation (2004):

  The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) mandated the use of a risk adjustment model, known as the CMS-HCC model, for MA plans starting in 2004. This model was designed to adjust payments based on the health status of beneficiaries, with a portion of the payment based on the new risk adjuster. 
• Phase-in Period:

  The implementation of the CMS-HCC model was phased in over several years. In 2004, 30% of a plan's payment was based on the risk adjuster, increasing to 50% in 2005, 75% in 2006, and fully implemented in 2007. 
• Evolution of Risk Adjustment:

  CMS has continued to refine and update the risk adjustment model over time, incorporating new conditions and data sources to improve accuracy and responsiveness to changes in beneficiary health status. 

  BUT THEY SEEMED TO HAVE FAILED IN THEIR OVERSIGHT.  
• Current Auditing Efforts:

  In recent years, CMS has increased its focus on Risk Adjustment Data Validation (RADV) audits to ensure the accuracy of diagnoses used for risk adjustment, with plans to extrapolate findings across entire populations. 

  The new rules now are that every diagnosis has to be validated by physicians notes in the chart.  

  Yes, the plans do need to be paid more for those that are sicker and are costing them more - it is the validation of this measure that now has to be verified with an audit not just on the hearsay of some home care visit or any other way.  

[CBtoo]

Speaking of risk adjustment, Bloomberg Prognosis published an article today (in the email I get anyway) that states that the insurers who write senior plans really messed up this year with how "priced" advantage plans and benefits in them (as in profits aren't nearly as high). 

It is titled "The Price is Wrong". 

The first two paragraphs are copy/paste below (likely I can't put it all here for copyright reasons and it is long). The are writing about medicare, medicaid and ACA plans.

"Every year, number crunchers at US health insurance companies look at their enrolled populations and calculate how many of them will break their arms, require a heart stent or be diagnosed with cancer. They use these figures to determine how much to charge in premiums to be able to cover patients' medical issues and still make a profit.

This year, the number crunchers have been spectacularly wrong — and that means prices are going up next year."

From a bit further in the article:
"On top of the policy changes, health insurance companies say medical expenses are being driven up by expensive drugs, more demand for mental health and substance abuse treatment, and aggressive billing by hospitals and other providers."

Clip again

"Medical costs in the broader commercial market are set to rise by 8.5% next year, according to a survey of actuaries by PwC. To cover costs going forward, insurers raise prices."

And another clip:
"With future insurance in doubt, patients may be seeking more medical care now while they still have coverage. That's set to boost medical spending this year, Centene said. It's another element of uncertainty in a business that hinges on making accurate predictions — and can unravel when they're wrong. — John Tozzi​"

WhIle some of the article is not about medicare, most of what they write about applies to all. PLUS with the budget deficit we will now have there will be a $500 BILLION cut to mediare over the next 10 years. A law from 2010 triggered this because of how high our deficit will be. 

In my opinion this means ALL of us will be in trouble with rates going up to cover reduced funding coupled with social security cuts by 26% in 2033 if we don't act to solve that one. Too bad I am young enough not to be dead then so as not to have to worry about it  LOL (that's a joke folks, a dark joke).

[GailL1]

@CBtoo 

Yep - get ready.

Medicare Part B premiums 

Medigap Premiums 

Medicare Part D cost

Medicare Advantage plans cost

There are almost 70 million of us on Medicare and more everyday and there is one thing that we all seem to do quite well - use our healthcare.  From preventive services to the new mental health coverage to the expensive weight loss drugs - although they are supposed to be for other DX than just straight weight loss.  

[Tonster521]

@gail1, Thanks for the info. It would be interesting to know the methodology that MA Plans use for affecting risk adjustments evaluations (RAE). Do they use medical info obtained from Physician visits (outpatient/inpatient), RNs, APRNs, Physician Assistants, or a combination of all? Or does a person with a past medical background or even a non-medical background (insurance company employees) make the RAE? Or is the RAE the result of computer program that utilizes ICD codes? I have not been in the healthcare funding business for about 20 years (2005). Back then, there were tens of thousand of ICD codes, maybe 50,000, is my guess. As I remember, the diagnoses with the greatest amount of codes were Cardio Vascular and Diabetes. The morbidity varied from person to person. I do not know nor could I find on the internet the formula that the CMS established for RAE payments. Moreover, if such formulas exist, they may change from year to year due to changes in medical procedures, new drugs, etc. In other words, some are dynamic or changing. 

From an auditing perspective, it looks like they CMS was initially overwhelmed by the amount of folks that elected MA over Traditional Medicare. I do not think that anyone expected more than 50% enrollment in MA. The forecast is even for greater percentages in the future, maybe as much as 65%. So, how could CMS address such exponential growth in MA and their audit requirements? They would have needed an army of auditors which they still need today in order to audit 20 to 30 million RAEs. I suspect CMS will outsource the "hands on" RAEs to a third party. That will provide at least some "arms length" protection against any litigation that may arise. As you know, CMS enters into contracts with MA insurers who have been in the healthcare risk business for years; and ,have not only empirical data, but also actuarial data regarding morbidity. As you know, we do not get healthier as we age. Statistics inform us that the chances (probability) of illness/disability is greater than death. The CMS knows this as well. 

As I mentioned in my reply, the audit will focus on medical records that are incomplete or missing information/pertinent data. In many cases, physicians are not sitting at keyboards entering data obtained from visits, laboratory, xrays, hospital confinements, etc. into medical records. For example, I live in an urban area with hundreds if not thousands of physicians within a half hour drive. Most, if not all, are connected to large physician groups that have administrative folks that type (enter data) via keyboards into computer databases/records at lightning speed. I am sure that there are still some physicians who are not part of large physician groups or are in rural areas that cannot cover the costs of extra administrative folks. So, any increased CMS audits will focus on record keeping. It is a start to determine if there was any skullduggery. If not, but medical records are incomplete and/or missing data, it will require MA insurers to increase their administrative staff and that will increase the cost of MA Plans. I do not believe the CMS wants to drive the MA insurers out of offering MA Plans and accepting healthcare risk.  

[CBtoo]

I think the exponential growth in Medicare Advantage plans is because agents write, something like, 65% of them and they get paid more than twice as much to write them vs a supplement and D. So duh if all of their income comes from commissions what are many of them going to do? Write Advantage plans as they will make more. They could solve that by making the commission the same across all plans advantage or supplements (plus D together) just for starters.

Sure some would still choose an advantage plan due to some of the other "freebies" however not all people who choose them qualify for food cards, etc. If one compares the max out of pocket of an advantage plan vs any supplement, supplement's win if you are going to hit the max. Further, since you have to pass medical underwriting to get into a supplement when your health declines and you now find them "cheaper" than an advantage plan, many won't, Of course preventing people from switching keeps the supplements full of healthy people too, not just the sickest of the sick...

There are no easy answers but when they are rewarding agents more for writing advantage plans than supplements and D, it is no surprise that the growth of them is huge,