This week, we are reading updates on Humana’s Medicare Advantage results, a summary on how a practice known as retrospective chart review impacts the Medicare Advantage market, and details on AMA’s concern with Medicare Part D formulary changes.

UPDATE 2 – Humana beats estimates on Medicare Advantage demand, raises forecast | CNBC, Reuters | August 1, 2018

Humana Inc topped Wall Street expectations for second-quarter profit on Wednesday as it sold more Medicare Advantage healthcare plans to the elderly and the disabled, prompting the U.S. health insurer to raise its full-year earnings forecast.

Humana has a significant presence in the Medicare Advantage market, a lucrative business for private insurers. Unlike its rivals, Humana is steering shy of large acquisitions and is instead focusing on partnerships and smaller deals while cementing its dominance in the Medicare Advantage business.

Read the full update on here.

Insurers profit from Medicare Advantage’s incentive to add coding that boosts reimbursement | Modern Healthcare | September 1, 2018

Health insurers have perfected a way to wring billions more in revenue from the Medicare program by combing patient medical charts for additional diagnosis codes to submit to the federal government for payment. 

The latest example of the massive returns that insurers reap from the practice known as a retrospective chart review was outlined in legal documents filed in a case against Indianapolis-based health insurer Anthem. The documents show Anthem pocketed more than $112 million in additional Medicare Advantage risk-adjustment payments in 2015 and $102 million in 2014 while spending little over $18 million each year to carry out the review program.

Identifying and documenting additional diagnosis codes to send to the CMS for risk-adjustment payment is perfectly legal if the patient’s medical record supports it. In fact, the way Medicare pays Advantage organizations encourages them to code all diagnoses possible. Traditional Medicare providers do not have that incentive.

See the full article on here.

AMA Expresses Concern with Medicare Part D Formulary Changes | HealthPayer Intelligence | September 4, 2018

New Medicare Part D formulary policies introduced by CMS in August may increase patient safety risks and complicate the prior authorization process, said AMA President Barbara L. McAneny, MD, to

In an emailed statement, McAneny contended that newly introduced guidelines to allow Part D plans to use indication-based formularies would likely reduce patient access to effective therapies and may create unanticipated patient safety risks.

“Rather than benefiting patients, the CMS proposal actually introduces unfair complexity to Medicare patients and further cements the role that insurance companies play in deciding treatment plans,” said McAneny. “This is not a recipe for good health.”

The AMA also believes that the Part D changes will create confusion among patients, especially those without high health literacy and experience with navigating complex regulations around prescription drugs.

Read the full article on here.