Medicare Advantage (MA) trends continue to show more promising avenues for reimbursement as expansion continues. Coding multiple diagnoses for one patient is a legal and suggested option with MA, offering effective payment for providers and broader options for beneficiaries.
As Medicare Advantage enrollment grows and creates a more substantial economy for the market, insurers are expected to collaborate with third-party coding organizations trained to uncover all diagnostic coding possibilities.
Medicare anticipates a payout of $200 billion to Medicare Advantage plans over the next decade unless the Centers for Medicare and Medicaid Services (CMS) chooses to modify the process and disallow Medicare Advantage plans from receiving a greater fee per diagnostic code than traditional Medicare plans.
The CMS offers Medicare Advantage providers a “per member, per month fee” for enrollees, which was previously determined by more narrow demographics, like sex and age. In 2004, a new risk-adjustment model was implemented, taking into account specific health conditions for each member. Medicare Advantage beneficiaries are now scaled with diagnoses consideration.
The payment system is designed to reimburse plans a higher amount for sicker patients with multiple diagnoses and to prevent health insurers from choosing healthy members.
This opens the door for increased diagnoses reporting and coverage and payment from the CMS. In 2016, Medicare Advantage payments were 2% to 3% greater than what would have been recovered if the same patients were enrolled in traditional, fee-for-service Medicare.
Additionally, higher Medicare Advantage payout rates allow room for expanded beneficiary care, such as health club access and vision policies, none of which traditional Medicare is capable of providing. In total, Medicare Advantage plans were reimbursed $210 billion in 2017 for 19 million seniors’ managed care.
Essentially, under Medicare Advantage, third-party vendors are able to assist with patient chart evaluation and coding, covering the broadest diagnoses spectrum possible before submission to CMS. The increased revenues are resulting in further expansion and also increased scrutiny for the appropriateness of coding.
The GIRS Payer Advocacy Compass® (PAC) team has focused on the trends in the Medicare Advantage Market to assist our clients with tracking the expansion taking place in these markets and the impact on patient benefits, coverage and payment for their medical technologies in this important payer market.
If you would like to expand coverage and payment for your accounts in key payer markets and are experiencing claims denials for your medical devices, drugs, biologics, or diagnostics, or if you need to improve the market uptake and patient access in key markets, our PAC team can assist you to meet your company goals.
To implement successful market access strategies, the GIRS Value Discovery Landscape Assessment® team can also conduct a Reimbursement Landscape Assessment to develop payer-desired strategies with clinical outcomes experts, coding experts, policy staff, reimbursement lawyers, and a panel of current insurer medical directors. This work will provide you with foundation reimbursement strategies that will influence and coordinate your clinical outcomes, marketing, and reimbursement strategies to result in the best market access outcomes. The PAC team can then implement these strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. Please contact us by email or call us at 1-844-514-4477. Also, follow our LinkedIn Company Page for more bi-weekly news on reimbursement trends, milestones, and achievements.