منابع مشابه
Upcoding or Selection? Evidence from Medicare on Squishy Risk Adjustment⇤
Risk adjustment is commonly used in health insurance markets to deal with problems of adverse selection and cream skimming by compensating health plans for insuring consumers whose diagnoses imply high expected costs. However, in all real world risk adjustment systems, insurers themselves report the diagnoses that determine enrollee risk scores and ultimately insurer payments. If risk scores ar...
متن کاملMedicare upcoding and hospital ownership.
Many hospitals in the 1990s many hospitals were accused of "upcoding" patient diagnostic related groups (DRGs) to increase Medicare reimbursements. We find that between 1989 and 1996, the percentage point share of the most generous DRG for pneumonia and respiratory infections rose by 10 points among not-for-profit hospitals, 23 points among for-profit hospitals, and 37 points in hospitals conve...
متن کاملHow Does Risk Selection Respond to Risk Adjustment? New Evidence from the Medicare Advantage Program.
To combat adverse selection, governments increasingly base payments to health plans and providers on enrollees’ scores from risk-adjustment formulae. In 2004, Medicare began to risk-adjust capitation payments to private Medicare Advantage (MA) plans to reduce selection-driven overpayments. But because the variance of medical costs increases with the predicted mean, incentivizing enrollment of i...
متن کاملMedicare skilled nursing facility reimbursement and upcoding.
Post-acute care provided by skilled nursing facilities (SNFs) is reimbursed by Medicare under a prospective payment system using resource utilization groups (RUGs) that adjust payment intensity on the basis of predefined ranges of weekly therapy minutes provided and the functionality of the patient. Individual RUGs account for differences in the intensity of care provided, but there exists sign...
متن کاملWill risk-adjustment decrease health care costs? New evidence from the Medicare Advantage Program∗
To combat adverse selection, governments increasingly base payments to health plans and providers on enrollees’ scores from risk-adjustment formulae. But because the variance of medical costs increases with the predicted mean, incentivizing enrollment of individuals with higher scores can increase the scope for enrolling “over-priced” individuals with costs significantly below the formula’s pre...
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ژورنال
عنوان ژورنال: Journal of Political Economy
سال: 2020
ISSN: 0022-3808,1537-534X
DOI: 10.1086/704756