How insurers could have gamed ACA risk adjustment
Oregon-based provider and insurer Zoom is being investigated for allegations it tampered with medical claims to make sure it didn’t have to pay into the risk adjustment pool for the Affordable Care Act (ACA) marketplaces.
Axios reports Zoom is “likely an aberration” in its alleged fraud. It's possible, however, that other insurers have taken similar strategies, as they've been known to overcharge Medicare Advantage’s risk adjustment program through overcoding, with one study estimating those practices could cost CMS $200 billion over the next decade.
In this case, Zoom supposedly changed the codes on claims for patients who were going to its own clinics and had Zoom as their insurer. For example, a patient with hypertension could have been upcoded to a more serious condition like congestive heart failure.
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John joined TriMed in 2016, focusing on healthcare policy and regulation. After graduating from Columbia College Chicago, he worked at FM News Chicago and Rivet News Radio, and worked on the state government and politics beat for the Illinois Radio Network. Outside of work, you may find him adding to his never-ending graphic novel collection.