Medicare Advantage coding article misses the big picture

Regarding “Taking advantage: Insurers profit from Medicare Advantage’s incentive to add coding that boosts reimbursement” (Sept. 3, p. 14), current risk scores for the Medicare Advantage patient population are far from accurate and are often the result of missed conditions, not simply coding deficiencies.

An IBM Watson analysis found that 30%-40% of chronic conditions are not captured for risk-adjustment purposes the very first year after diagnosis. Those numbers only increase the second, third and fourth year after initial diagnosis. To make matters worse, many times chronic conditions that are being missed for risk-adjustment purposes are often also missed for chronic care management purposes, leading to poorer patient outcomes and low and inaccurate reimbursements.

The article gives the example of an 84-year-old male patient with diabetes who without complications would receive $6,765 in reimbursements to his Medicare Advantage plan. But “tack on a diagnostic code for vascular disease and that same diabetic patient’s Medicare payment would jump to $9,796,” the author states. While that is true, this statement misses the big picture of the CMS’ risk-adjustment model. In the first example, the patient was likely not being treated for vascular disease, which often leads to more serious and costly conditions such as nephropathy, neuropathy and cardiovascular complications. The CMS would much rather pay an extra $3,031 than cover the costs of resulting amputations, dialysis and bypass surgery.

Arhama W. Rushdi Philadelphia