Monday: Medicare Advantage rules change – How much will it really hurt?

Wolters Kluwer risk adjustment coding expert Melissa James predicts impact of final rule

Waltham, MA March 31st, 2023 –

WHAT: On Monday, April 3rd, the U.S. Department of Health Center for Medicare and Medicaid Services (CMS) is set to release new rules aimed at changing how Medicare Advantage plans are paid for 2024. The proposed changes were first released in February, and the healthcare industry, particularly the insurance/payer sector, has been discussing the potential impacts since.

WHO: Melissa James, senior healthcare consultant, Wolters Kluwer, is a risk adjustment expert with 25+ years of coding experience; formerly with payers, where she internally audited the Medicare Advantage plans’ risk adjustment, performed chart reviews, and completed regulatory and compliance audits.

“These are substantial changes to codes that will no longer risk adjust, whether they’re good I can’t say. Some of the biggest changes come from the potential de-emphasis on social determinants of health, such as ICD-10 removals of malnutrition and certain depression diagnoses. Other notable changes include “constraining” diabetes and congestive heart failure diagnoses."

“Larger health plans may reduce benefits and increase premiums, however I fear there might be a more significant impact on smaller health plans that may not be able to continue to operate in the space. This could affect people regionally in what are considered healthcare deserts where the only options are small health plans that offer Medicare Advantage. These healthcare deserts often have a higher prevalence of impacted disease such as diabetes and congestive heart failure, which were significantly hit by the proposed payment change. These regions will be disproportionally affected due to their case mixes.”

“One speculation that I agree with is that companies that own their own risk-bearing providers and have Medicare Advantage plans will likely be impacted the most. They will have to spend a lot of time educating physicians and coders to code accurately and must put the right emphasis on capturing chronic conditions with their providers.”

HOW: Contact Ashley Beine at [email protected] to schedule an interview with Melissa James. Journalists may also publish quotes above with proper attribution.

Wolters Kluwer Health provides trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers and students in effective decision-making and outcomes across healthcare. The division of Wolters Kluwer supports clinical effectiveness, learning and research, clinical surveillance and compliance, as well as data solutions.