S.1105 - No Unreasonable Payments, Coding, Or Diagnoses for the Elderly Act; No UPCODE Act (119th Congress)
Summary
S.1105, the "No UPCODE Act," aims to amend Title XVIII of the Social Security Act to improve risk adjustment under Medicare Advantage. The bill seeks to prevent unreasonable payments, coding practices, and diagnoses within the Medicare Advantage program. It mandates the use of two years of diagnostic data for risk adjustment and excludes diagnoses collected from chart reviews and health risk assessments.
Additionally, the bill requires the Secretary to evaluate and adjust for coding pattern differences between Medicare Advantage plans and providers under traditional Medicare (Parts A and B). This evaluation would be reported publicly and adjustments made to account for the impact of these coding differences.
The intended goal is to ensure more accurate and fair payments to Medicare Advantage plans, reducing potential overpayments due to aggressive coding practices.
Expected Effects
The bill's passage would likely lead to changes in how Medicare Advantage plans are reimbursed. It would probably reduce payments to plans that currently rely heavily on chart reviews and health risk assessments for diagnosis coding.
It could also incentivize more accurate and standardized coding practices across all Medicare programs. Ultimately, the goal is to reduce wasteful spending and ensure that Medicare Advantage payments accurately reflect the health status of enrollees.
Potential Benefits
- Reduced potential for overpayments to Medicare Advantage plans due to coding practices.
- Increased accuracy in risk adjustment, leading to fairer allocation of resources.
- Public reporting of coding pattern differences, promoting transparency and accountability.
- Potential savings for taxpayers through more efficient use of Medicare funds.
- Discourages potentially unnecessary or inflated diagnoses.
Most Benefited Areas:
Potential Disadvantages
- Medicare Advantage plans may face reduced revenue, potentially leading to benefit cuts or increased premiums for enrollees.
- The implementation of new procedures for identifying and verifying diagnoses could be complex and costly.
- Some argue that excluding diagnoses from chart reviews and health risk assessments may understate the true health needs of enrollees.
- There is a risk that plans may shift coding efforts to other areas, potentially creating new avenues for overpayment.
- The evaluation of coding pattern differences may be subjective and lead to disputes between plans and the government.
Constitutional Alignment
The bill appears to align with the general welfare clause of the Constitution, as it aims to improve the efficiency and accuracy of Medicare payments. Article I, Section 8 grants Congress the power to collect taxes and provide for the general welfare of the United States.
By addressing potential overpayments and promoting responsible coding practices, the bill seeks to ensure that taxpayer dollars are used effectively in funding healthcare for seniors. There are no apparent conflicts with specific constitutional provisions regarding individual rights or federalism.
However, the specific mechanisms for implementing the bill, such as the identification and verification of diagnoses, would need to be carefully designed to avoid infringing on individual privacy rights or creating undue burdens on healthcare providers.
Impact Assessment: Things You Care About ⓘ
This action has been evaluated across 19 key areas that matter to you. Scores range from 1 (highly disadvantageous) to 5 (highly beneficial).