No UPCODE Act No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act
Impact
If enacted, SB1002 is likely to significantly impact state laws concerning Medicare Advantage and the broader healthcare landscape for elderly citizens. By modifying the risk adjustment process, the bill intends to improve the accuracy of payment adjustments, ensuring that payments are more closely aligned with actual healthcare needs as reflected in diagnostic data. This change aims to minimize instances of over-coding and reduce unnecessary healthcare costs while protecting insurers and healthcare providers from unwarranted financial penalties due to discrepancies in coding practices.
Summary
SB1002, or the 'No UPCODE Act,' aims to amend Title XVIII of the Social Security Act to enhance the risk adjustment methodology for Medicare Advantage. The legislation seeks to address concerns regarding the current risk adjustment process, specifically by altering the way diagnoses are accounted for in determining payment adjustments for Medicare enrollees. The bill proposes that for payment calculations, diagnoses obtained from chart reviews and health risk assessments will be excluded, which advocates argue is necessary for a fairer system that better reflects the health status of seniors enrolled in Medicare Advantage plans.
Contention
One notable point of contention surrounding SB1002 is the exclusion of diagnoses from chart reviews and health risk assessments in establishing payment adjustments. Critics of the bill may argue that this exclusion could lead to an underestimation of the healthcare needs of certain populations, particularly those who may not have comprehensive consultations. Additionally, stakeholders may be concerned about whether the proposed changes adequately account for variations in coding practices across different Medicare Advantage plans, thereby potentially impacting the financial viability of those plans and their ability to deliver quality care.
No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act or the No UPCODE Act This bill modifies certain factors that are used to determine Medicare Advantage (MA) payments, particularly relating to health status and related data. Specifically, the bill requires the Centers for Medicare & Medicaid Services (CMS) to use two years of diagnostic data in its risk adjustment methodology for MA payments. It also prohibits the CMS from using diagnoses that are collected from chart reviews or health risk assessments when adjusting payments based on health status. The CMS must also take into account any differences in coding patterns between MA and traditional Medicare when determining MA payment adjustments.