Medicare Advantage risk assessments driving billions in costs each year

Published: Fri, 05/10/24

Updated: Fri, 05/10/24

Link to all things medical coding & billing

Medicare Advantage risk assessments driving billions in costs each year

Medicare Advantage plans have come under fire for upcoding that can increase the payouts they receive, and regulators point to health risk assessments as a likely culprit in this increase in coding intensity. A new study published this week in Health Affairs adds to the body of evidence around these assessments. The analysis, led by researchers at Brown University, dug into encounter data from 2019 and found that...

Defenses Against Medicare Audits Based on Use of Artificial Intelligence (AI): Part III

Is there an arms race involving using technology for submitting claims and auditing them? In one example, an electronic health record system was deployed that would increase reimbursements. It would do this by inserting into patient charts default templates that allowed physicians and others to copy in information from patient records – assuming, of course, that...

Telehealth boosts outcomes, spending, as regulatory flexibilities are in question

The rapid adoption of telehealth services, accelerated by the COVID-19 pandemic, has had a positive result on outcomes and resulted in a boost in healthcare spending, according to a report in Health Affairs. The researchers investigated the relationship between the adoption of telemedicine and its impact on costs and quality of care across various health systems.

Diagnosis Pitfalls to Look for When Seeking to Avoid Denials

A recent study from the healthcare solutions company Premier indicated that $19.7 billion is what hospitals and health systems are spending annually on handling and appealing denials. Yes, that is “billions,” with a “B.” There are several reasons claim denials can occur, including but not limited to medical necessity, claim edits, pre-authorization, and others...

Defenses Against AI-Based Medicare Audits: Part II

Legal scholars, practitioners, and other observers have grappled with the legal dimensions of artificial intelligence. As early as 1992, Solum discussed the case for considering AI to be a legal person. As of 2014, writers still were arguing that AI was unable to present “higher-order cognition” needed by the legal profession. But this time has passed. Today, particularly for routine matters, such as one might...

Emerging Legal Defenses Against AI-Assisted Medicare Audits: Part I

As we know, artificial intelligence is in the spotlight these days. It is being adopted in almost every sector of the economy. It is a commercial product, and the salespeople all argue that AI promises to yield almost incredible improvements in efficiency and accuracy in fields as diverse as supply chain management, screening candidates for HR departments, driving...

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