As open enrollment approaches this week, Medicare Advantage is likely to account for more than half of all Medicare enrollments in 2023.
Plans' risk adjustment procedures are being scrutinized more closely as membership soars, and regulators are cracking down harder on program payouts. Additionally, this year's star ratings are expected to decrease as new flexibilities implemented in response to the pandemic are eliminated and insurers are required to factor in health equity when calculating their ratings.
This year, Medicare Advantage (MA) plan star ratings reached all-time highs, which enabled plans to receive sizable quality bonuses.
But there has been a significant decrease for 2023 as a result of the elimination of pandemic flexibility and new health equity initiatives. According to numerous analysts and analyses, this might result in a revenue loss of $800 million.
In an interview with Fierce Healthcare, Cynthia Henry, manager of Medicare Advantage solutions at the insurance technology company ZeOmega, stated that "there is going to be a national average decline in most measurements." "With the exception of Part D metrics, we are looking at reductions in pretty much every area."
In addition to attracting new competitors, Medicare Advantage's (MA) rapid expansion has raised questions about how plans handle risk adjustment, particularly in light of worries about Medicare's long-term financial stability.
Recent reports from federal watchdogs and experts have increased scrutiny over risk adjustment practices, which change payments to plans based on patient health. Specifically, it has been found that some plans are receiving excessive payments from Medicare as a result of up-coding, which is a practice where plans add extra diagnoses to codes to increase patient risk scores. The payment to the plan increases as the risk score rises.