Risk Adjustment in Medicare Advantage Explained

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Risk Adjustment in Medicare Advantage Explained

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AHealthcareZ - Healthcare Finance Explained

Күн бұрын

Risk Adjustment in Medicare Advantage Explained. Learn:
1) What a Hierarchical Condition Category (HCC) is.
2) What the Risk Adjustment Factor (RAF) is.
3) How health insurance companies maximize HCCs and RAFs to maximize their payments per beneficiary from CMS (the Centers for Medicare and Medicaid Services).
4) About the alleged fraud and over-billing by health insurance companies in Medicare Advantage as reported by the New York Times.
Sources:
www.imohealth....
cdn1-originals...
bettermedicare...
www.medicareri...
www.fierceheal...
www.nytimes.co...
aspe.hhs.gov/s...
www.statnews.c...
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Пікірлер: 28

@samchoi4502 Жыл бұрын

You and these videos are invaluable - We are witnessing in real time the privatization of Medicare in front of our eyes - (Just like the penal system and huge parts of the defense industry ) Single payer doesn’t look so bad 😢

@ahealthcarez Жыл бұрын

Thank you for sharing your perspective.

@malcorub Жыл бұрын

I just landed a job in the Medicare Advantage space for one of said insurance companies. This video helps me understand this new world I just jumped into! Thank you!

@ahealthcarez Жыл бұрын

Thank you for watching and for your comment.

@sushibooshi 5 ай бұрын

Thank you for all these videos dr.bricker. As someone that is new to the field these videos have been very insightful!

@ahealthcarez 5 ай бұрын

Thank you for watching.

@narekpapukyan5455 Жыл бұрын

Dr. Bricker thank you again for your analysis. This is absolutely invaluable information!

@ahealthcarez Жыл бұрын

Thank you for watching and for your feedback.

@JeromyTimmer 6 ай бұрын

One thing that he didn't mention in the video is that HCC capture is a zero-sum game. The CMS budget does not magically increase when we capture HCC codes. CMS "normalizes" RAF scores so that the average value across the nation is 1.0. This adjusted number is the Risk Score. So if United is really aggressive with HCC capture and blue cross isn't, then blue cross would get paid less even thought their patients aren't any healthier. Everyone in a full risk contract has to get good at this, or they will get paid less.

@ahealthcarez 6 ай бұрын

Thank you for sharing. Everyone trying to get a bigger piece, but the pie isn’t growing.

@Itsme-jv4cd 12 күн бұрын

Fraud is one of the reasons we are allowed to get out of a Medicare Advantage plan . How do we make our case to get out of our Medicare Advantage plan?

@DataTranslator Ай бұрын

I think you forgot to mention ACOs and value-based care as a way to controlling for over coding

@tomm7505 Жыл бұрын

This is surprising. I thought that with MA plans, that the insurance company was taking all of the risk for treating the health of the patients and all that CMS had to do was pay the insurance company a flat monthly payment for each beneficiary. I didn't know that CMS had to pay even more to insurance companies for sicker patients. Don't you think it kind of defeats the purpose of the having MA plans if CMS has to continually pay additional amounts? Am I missing something?

@ahealthcarez Жыл бұрын

That is one reason why MA costs the government more than Traditional Medicare. Thank you for watching.

@tomm7505 Жыл бұрын

@@ahealthcarez And another reason why (when I turn 65 in April 2024) I'll be going with a MedSupp plan instead of MA. Crazy.

@poojapatwal6525 Жыл бұрын

Sad. Americas healthcare is so complicated. Medicare basically doesn't know what it's paying for and trusts these corporate insurance companies to do their job? Wow. Just wow. No wonder the federal government is under their mercy. But the saddest part is, more hell for doctors to fight for preauthorizations and as doctors get tired of arguing, patients are dying.

@ahealthcarez Жыл бұрын

All good points. Thank you for watching and sharing your thoughts.

@kevinsurles26 Жыл бұрын

This is not true. healthcare plans actually care about the well-being of their members. we aren’t just a tall building on Wall Street. The healthcare companies are made up of Americans that have Medical concern themselves and/or love ones that rely on their company to provide human and compassionate care. Please don’t buy into the harsh rhetoric that’s on display. This gentlemen is not painting a complete picture of the healthcare system, specifically MA plans

@thatwasinteresting3319 5 ай бұрын

@@kevinsurles26 BS it's time for the Insurance companies to justify their existence. They offer no actual value add to the system except as a system to extract money from the healthcare system and enrich investors while claiming to be not for profit.. They do not provide patient care and their models actually do not encourage providers to actually guide their patients to seek healthier lifestyles. The majority of the US healthcare diseases are lifestyle diseases. Obesity, addiction, Mental health etc. None of this is will get better as long as insurance companies and pharma are in charge of the healthcare system.