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Risk Adjustment and Incentives for Upcoding in Medicare

In February 2023, CMS CMS published a notice of proposed rulemaking to update their HCC risk adjustment algorithm (v28). These changes included (i) leveraging ICD-10 rather than ICD-9 codes as the primary building blocks, (ii) use of 115 HCC indicators rather than 79, and (iii) constraining some coefficients to be identical across severity levels (e.g., […]

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Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage

Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital. The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — […]

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Reconsidering and Measuring Patient Access in Medicaid

Recent Medicaid policy discussions have focused on coverage issues because millions of beneficiaries have been disenrolled during the unwinding of COVID-19 pandemic–era eligibility protections. But access to care during a person’s enrollment in Medicaid is an equally important issue, and one that is particularly thorny to measure and address.

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Provider Strategy reports on market developments and insights related to the healthcare provider workforce. Our publication is committed to improving the healthcare professional workforce, utilization of providers, and ultimately supporting thought leadership in workforce innovation.

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