Quote:
Originally Posted by Rainger99
In contrast, Medicare Advantage shifts the financial risk to the private insurance company, which receives the fixed payment and manages all claims.
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That is only partially true. It is not a fixed payment in the Medicare Advantage system. CMS pays the MA insurance company a _risk-adjusted_ amount for each beneficiary. This means CMS’s MA payment to the insurance company is higher for sicker beneficiaries and lower for healthier beneficiaries. See the first link in my previous message. One aspect of this is a medical provider might upcode their services to make patients appear sicker so the CMS payment from the government is higher. Medicare Advantage is a complicated business model, not to mention the complex metrics for assessing the level of health for each MA beneficiary. It’s sort of like actuarial work and involves specialists and computer software.