MA plans are projected to receive at least $20 billion
in additional payments due to differential
coding intensity in 2026
Enrollees in Medicare Advantage have much higher rates of coding than their peers in Traditional Medicare. The MEDICODE Report Card aims to inform the public about which plans receive the most additional payment from risk score differentials.
Additional Payments to the Ten Largest Medicare Advantage Parent Companies due to Risk Code Differential
Estimates are from an analysis of 2023 Medicare Advantage Encounter data projected forward to 2026 dollars. Estimates were calculated using a modified version of the DECI method. Each bubble represents a company. The bubble size represents how many enrollees are in that company. The x-axis is the spending difference per member associated with differential coding intensity. The y-axis is the aggregate spending difference across the entire company due to differential coding intensity.
These estimates include CMS's 5.9% coding intensity adjustment and are calculated entirely from the V28 model.
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What Explains Differential Coding Intensity
Chart Reviews
MA Plans have the ability to update diagnoses included in beneficiary records through Chart Review encounters. Below, we calculate the percentage increase in risk scores due to codes added in Chart Reviews alone.
Plans can conduct at-home Health Risk Assessments (HRA) which capture additional codes without necessarily leading to additional care. Below, we calculate the percentage increase in risk scores resulting from HRA-captured diagnoses that don’t appear elsewhere in the patient’s records.
Health Risk Assessments
Throughout this website, we use a modified version of the Demographic Estimate of Coding Intensity (DECI) approach used by MedPAC and others to compare measured risk to expected risk among demographically similar beneficiaries. More details on how we calculated these scores can be found on the Documentation page.
DECI Estimates
What proportion of differential coding intensity is explained by chart reviews and health risk assessments?
The chart depicts the percentage point impact of differential coding intensity amongst the top ten Medicare Advantage companies. Note: Chart review and health risk assessment differentials are not additive, as some HRAs have their own chart reviews.
About
The goal of this research project is to shed light on differential coding practices across Medicare Advantage insurers and to make this information transparent and publicly available. This work was conducted by researchers at the Center for Advancing Health Policy through Research (CAHPR) at the Brown University School of Public Health. Our estimates are based on methods previously published in peer-reviewed literature. By including estimates, we make no representation concerning the truthfulness or accuracy of any coding; we only report on observed differences in coding. Our estimates may vary from those reported by other groups such as MedPAC due to differences in available data.