With billions of federal dollars at stake, there are still plenty of opportunities for “gaming” that the government could address through a more simplified system, said Ceci Connolly, CEO of the Alliance of Community Health Plans, a trade group for nonprofit health insurers.
Alliance Vice President Michael Bagel agreed: “We spend, as an industry, billions if not tens of billions of dollars in administrative costs on risk adjustment. That’s literally just on documenting risk so that we can get paid properly. … Is that a good use of taxpayer dollars?”
Yet the financial incentives have pushed more plans to try pumping up risk adjustment revenue, said Miller, the former MedPAC executive director.
“I think a lot of plans didn’t want to take the risk to get in initially, because the upcoding might get shut down,” said Miller, who today is executive vice president of health care at Houston-based Arnold Ventures. “But then as they saw more and more insurers doing it, they probably felt like they had to get into the game to stay competitive.”
Source: How insurance industry ‘stranglehold’ blocked Medicare reform
