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., diabetes, heart failure). The new algorithm will be phased in during 2024–2026.

Risk Adjustment and Incentives for Upcoding in Medicare

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State Coverage and Reimbursement of Antiobesity Medications in Medicaid

Recently, glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have emerged as safe and effective treatments for obesity, with ability to improve long-term cardiovascular outcomes. However, their high cost has raised concerns about their budgetary effect, particularly for public insurance programs. Medicare Part D plans statutorily cannot cover antiobesity medications, but state Medicaid programs have more […]

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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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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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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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