Insurers carry out chart reviews to verify alignment between medical records and information submitted by providers. While these reviews can help payers understand a beneficiary’s needs and increase payments to accommodate anticipated costs, they could also be used inappropriately.
“Chart reviews can also identify diagnoses that are inaccurate, no longer an active consideration or unrelated to the clinical care enrollees receive, and thus potentially inappropriate to submit to CMS for payment purposes,” a Nov. 20 KFF report said.
A March study from the Annals of Internal Medicine estimated an extra $33 billion in payments to plans in 2021 due to coding differences.
Here are four takeaways from KFF’s analysis of 2022 Medicare Advantage encounter data:
1. Sixty-two percent of MA enrollees, or roughly 18 million people, underwent at least one chart review that year.
2. One in 6 MA enrollees had a diagnosis tacked on in chart review that added a condition category affecting an individual’s risk score. Just over 1% had a diagnosis removed that prompted a category to no longer play into the risk score.
3. About 30% of enrollees with at least one chart review had a diagnosis added that boosted their Medicare Advantage plan’s federal payment.
4. Among major insurers, CVS Health Corp., Elevance Health, UnitedHealth Group and Centene saw the largest shares of enrollees undergoing chart reviews.
