HA415 Unit 9 Coding Intensity Seminar Reflection Example

Six Years of Chart Review and One Argument I Could Not Answer: A Seminar Reflection on a Debate Over Coding Intensity in Medicare Advantage, What Moved Me Partway and Where I Still Would Not Move

[Student Name]

Purdue University Global

HA415: Health Care Policy and Economics

Unit 9 Seminar Reflection

[Instructor Name]

[Date]

The writer's work history and the seminar exchange are composite; the reflection shows the form of a seminar response and does not describe a real plan or person.

The Rule Under Debate

Medicare pays Medicare Advantage plans a monthly amount for each enrollee, adjusted by a risk score built from the enrollee's diagnoses. More recorded diagnoses mean a higher score and a higher payment. CMS applies an across-the-board reduction to account for plans coding more intensively than traditional Medicare. The seminar debated whether that reduction should be larger.

My Starting Position

I argued against a larger cut. In my old job, I reviewed charts to find diagnoses that physicians had documented but nobody had coded. Every code I submitted was supported by the record. Traditional Medicare, I said, undercodes because nobody has a reason to code completely, so Medicare Advantage scores are more accurate, not inflated. I was defending the accuracy of each code, and my classmate was not disputing it; she was asking what happens to the payment when one side codes everything and the other does not.

The Argument That Moved Me

My classmate, who works in a hospital finance office, made a simple point. Risk adjustment compares Medicare Advantage enrollees with traditional Medicare beneficiaries. If plans code completely and traditional Medicare does not, the same person receives a higher score in a plan than outside it, and Medicare pays more for that person without any change in health. She cited a study that followed people who switched into Medicare Advantage and found their risk scores rose compared with similar people who stayed in traditional Medicare (Geruso & Layton, 2020). Another analysis measured how much faster risk scores grew in Medicare Advantage than in traditional Medicare for comparable populations (Kronick & Welch, 2014). I had no answer. I had always asked whether each code was true. She was asking whether the payment system could tell the difference between true codes found by effort and the same conditions left uncoded elsewhere.

Where I Moved

I now accept that coding intensity raises payments to Medicare Advantage plans above what the same enrollees would cost in traditional Medicare, and that the current reduction may be too small. The Medicare Payment Advisory Commission has reported for several years that Medicare Advantage risk scores are higher than they would be for the same people in traditional Medicare (Medicare Payment Advisory Commission, 2024).

Where I Did Not Move

I still do not accept that all extra coding is gaming. Some conditions really are undercoded in traditional Medicare, and plans that find and manage them may improve care. I argued in the second round that the fix should be a larger adjustment combined with better coding in traditional Medicare, not a ban on chart reviews. Several classmates disagreed, and I have not changed my mind on that point.

How My Experience Still Helped

My chart review years were not useless in the debate. When a classmate suggested that plans simply invent diagnoses, I could explain how codes are audited and why most chart review findings are documented by a physician. That point helped the group separate two different problems: false codes, which audits can catch, and complete coding of real conditions, which audits cannot fix because the codes are true. Making that distinction was my most useful contribution, and it came from the work I had arrived to defend.

What I Learned About Arguing

I came to defend my old work and spent the first round defending something nobody had attacked. The useful question was not whether my codes were honest but what the system did with them. I want to listen for the actual claim before answering next time.

What I Would Tell My Former Colleagues

The work they do is accurate, but its effect on payment depends on a comparison they do not control. If traditional Medicare coding stays incomplete, a fair system has to adjust for the gap, even if each chart review is honest.

What Still Puzzles Me

I am unsure how large the right adjustment is. Estimates differ, and a cut that is too large would punish plans that code accurately and care for sick enrollees well. I would want to see evidence by plan, not only averages. I would also want to know whether plans with the highest coding intensity deliver better care for the conditions they code, since that would change how I judge the extra payment. If they do, part of the payment may be buying something real; if they do not, the case for a larger cut is stronger.

References

Geruso, M., & Layton, T. (2020). Upcoding: Evidence from Medicare on squishy risk adjustment. Journal of Political Economy, 128(3), 984-1026. https://doi.org/10.1086/704756

Kronick, R., & Welch, W. P. (2014). Measuring coding intensity in the Medicare Advantage program. Medicare & Medicaid Research Review, 4(2), E1-E19. https://doi.org/10.5600/mmrr.004.02.sa06

Medicare Payment Advisory Commission. (2024). Report to the Congress: Medicare payment policy. MedPAC.