ReviewMedical care2021
Medicare Advantage Chart Reviews Are Associated With Billions in Additional Payments for Some Plans.
Review in Medical care, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. An erratum has been issued. Cited by 21 papers.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
21 citing papers in PubMed.
- Endpoint assessment via routinely collected data generates estimates comparable to randomized controlled trial data: analysis of a cluster-randomized trial on fall injury prevention.Journal of clinical epidemiology · 2025Trial
- Risk Adjustment in the Medicare Advantage Population Using Encounter Data.Health services research · 2026Article
- Transcatheter Aortic Valve Replacement (TAVR) in Medicare Advantage and Medicare Fee-for-Service: Differences in Patient Characteristics, Utilization, and Outcomes.Circulation. Population health and outcomes · 2026Article
- Identification of prevalent dementia in Medicare Advantage encounters, compared with rigorous cohort assessments.The journals of gerontology. Series A, Biological sciences and medical sciences · 2026Article
- Heterogeneous responses to risk-adjustment reform: evidence from dementia diagnosis in Medicare Advantage.Health affairs scholar · 2026Article
- Chronic Conditions and Mortality in Medicare Beneficiaries Before and After the COVID-19 Pandemic.JAMA network open · 2026Article
- Exposure to the new Medicare Advantage risk adjustment model varies across insurers.Health affairs scholar · 2026Article
- Differences in the Measurement of Comorbidities Based on ICD-10-CM Coding Definitions Using Medicare Advantage Encounter Data and Fee-For-Service Claims.Medical care · 2026Article
- Perioperative Costs of Elective Surgical Procedures in Medicare Advantage Compared With Traditional Medicare.JAMA health forum · 2025Article
- Validation of Medicare Advantage Claims for Long-Term Outcome Assessment in Low-Risk Aortic Valve Replacement.Circulation. Cardiovascular quality and outcomes · 2025Article
- Prevalence of Chronic Medical Conditions Among Medicare Advantage and Traditional Medicare Beneficiaries.Annals of internal medicine · 2025Article
- Osteoporosis testing and treatment remain low in both Traditional Medicare and Medicare Advantage.Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA · 2025Article
- Coding intensity variation in Medicare Advantage.Health affairs scholar · 2025Article
- Evaluation of Low-Value Services Across Major Medicare Advantage Insurers and Traditional Medicare.JAMA network open · 2024Article
- Validation of a Rule-Based ICD-10-CM Algorithm to Detect Fall Injuries in Medicare Data.The journals of gerontology. Series A, Biological sciences and medical sciences · 2024Article
- The mechanics of risk adjustment and incentives for coding intensity in Medicare.Health services research · 2024Article
- Coding Intensity Through Health Risk Assessments and Chart Reviews in Medicare Advantage: Does It Explain Resource Use?Medical care research and review : MCRR · 2023Article
- Role of Patient Sorting in Avoidable Hospital Stays in Medicare Advantage vs Traditional Medicare.JAMA health forum · 2023Article
- Paying for Medical and Social Complexity in Massachusetts Medicaid.JAMA network open · 2023Article
- Opening the black box: Evaluating the care of people with serious illness in Medicare Advantage.Journal of the American Geriatrics Society · 2021Article
Corrections and comments
- Commented on by
- Erratum issued
Authors and funding
2 authors.
Funding
Abstract
backgroundIn the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees' number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments. Recently the Government Accountability Office released a report raising concerns about the use of these chart reviews as a potential tool for upcoding.
objectivesTo measure the extent to which plans receive additional payments for chart reviews, and the variation in chart reviews across plans. RESEARCH
designIn this cross-sectional study we use 2015 MA Encounter data to calculate how many additional diagnoses codes were added for each enrollee using chart reviews. We then calculate how these additional diagnosis codes translate to additional reimbursements across plans. SUBJECTS: A total of 14,021,692 beneficiaries enrolled in 510 MA contracts in 2015. MEASURES: Individual and contract level hierarchical condition category codes, total plan reimbursement.
resultsChart reviews were associated with a $2.3 billion increase in payments to plans, a 3.7% increase in Medicare spending to MA plans. Just 10% of plans accounted for 42% of the $2.3 billion in additional spending attributed to chart review. Among these plans, the relative increase in risk score from chart review was 17.2%. For-profit plans engaged in chart reviews substantially more frequently than nonprofit plans.
conclusionsGiven the substantial and highly variable increase in payments attributable to chart review, further investigation of the validity of this practice and its implications for Medicare spending is needed.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.