Insurance Fraud: Opinion by HENRY STERN

This strikes me as perverse:

In theory, if the system works, it could make insuring a patient with diabetes more attractive than insuring a similar patient without diabetes. Covering a patient who has diabetes and has had terrible medical care may look even better, because an insurer could collect extra risk adjustment cash for that patient while using good care management to reduce the patient’s medical bills.”

As FoIB Allison Bell notes, an immediate problem is that the implied mechanism here looks like the health care version of a credit score, and “[c]onsumers may not be thrilled to learn that insurers are assigning them risk scores.”

I’d agree, if they ever even learned of its existence. But this has been kept so well under the radar that I doubt whether many non-industry folks know about it (heck, I wonder how many industry folks know!).

It actually gets worse, though:

CMS recently began offering health insurers HHS-RADV training. The agency wants insurers to send it HHS-RADV data reports by April 30, 2016.”

That’s the agency’s Risk Adjustment Data Validation program, which seeks to collect health care usage data from carriers. And how is this data then used? Well, carriers have an incentive to make their own insureds look as sick as possible in order to hold onto (or get more of) that sweet, sweet risk corridor cash (and BTW, rotsa ruck with that).

On the gripping hand, it’s hard to feel much sympathy for carriers (thanks, AHIP!).