A group representing nonprofit health plans is raising concerns over what it claims is a wide variation in Medicare Advantage risk adjustment scores across insurers, leading to what it calls a “gaming” of MA payments to the benefit of for-profit insurers.
The Alliance of Community Health Plans compared CMS data to its nonprofit member health plans. The average MA risk score in 2023 at UnitedHealthcare was 36.2% higher than ACHP members and Humana’s was 19.2% higher. The report also found a significant average per-patient difference in payments to plans that year: UnitedHealthcare was $785.64 higher per patient than ACHP member plans and Humana was $423.24 higher per patient.
“Risk adjustment was a well-intentioned concept that has grown out of control and [is] overrun with abuse,” ACHP President and CEO Ceci Connolly said in a news release accompanying the report.
The report highlighted how the carriers could be “wasting tens of billions of taxpayer dollars each year.” ACHP proposed streamlining the risk-adjustment model, focusing on fewer, substantiated conditions and demographics, rather than many possible diagnoses.
