Pay Change Could Wreck Medicare Advantage Provider Networks, Group Predicts

The Change

CMS fears that Medicare Advantage plans are hurting the risk-adjustment system by working too hard to code for common chronic conditions such as diabetes, arthritis and lupus.

To adjust for high Medicare Advantage plan risk scores, CMS wants to stop including 2,300 diagnostic codes that are used much more often by Medicare Advantage plan providers than by providers who treat Medicare fee-for-service patients.

The move would include the codes for conditions such as major depressive disorder, diabetes with chronic conditions, vascular disease, rheumatoid arthritis and lupus.

Susan Dentzer, the CEO of America’s Physician Groups, called that proposal “supremely irrational.”

Physician group practices believe that “caring for disadvantaged Medicare Advantage enrollees will no longer be viable, and that they will have no choice but to abandon them and return to fee-for-service Medicare payment, which remains largely unaccountable for total costs and quality,” Dentzer said.

Susan Dentzer. (Photo: America’s Physician Groups)