Providers treating Medicare Advantage patients with dementia, depression and frailty may not be getting reimbursed fairly under Medicare, researchers argued in a recent viewpoint published in JAMA.
The Centers for Medicare & Medicaid Services’ hierarchical condition categories (CMS-HCC) risk adjustment model, which rates patients based on how sick they are, doesn’t account for the conditions — ultimately affecting Medicare reimbursements, they wrote.
The researchers argued the agency could address the issue by adding diagnostic codes for depression and dementia to the clinical conditions under the CMS-HCC model. They also pushed for adding claims-based frailty measures and incorporating social risk into current models.
“While it’s an unintended consequence of the current Medicare payment policy, those who are among the most vulnerable are less likely to get the care that they need,” Kenton Johnston, Ph.D., lead author and Saint Louis University College for Public Health and Social Justice professor, said.
“This disparity has already created an incentive for providers and plans to avoid treating Medicare beneficiaries with those conditions.”
They added that any concerns CMS may have regarding over-coding to increase reimbursement could be addressed through existing fraud procedures Medicare has in place.
“While fraud and abuse protections could and should be strengthened, it is unfair for CMS to penalize clinicians and health plans that care for vulnerable patients because of potential fraud that can best be handled using other more effective means that would not create inequitable reimbursement,” they wrote.
More skilled nursing facilities are becoming institutional special needs plans (I-SNPs), which is an MA insurance model.