Medicare Watch

Your Weekly Medicare Consumer Advocacy Update

How to Maximize Use of Health Care Data within Medicare

August 14, 2014

Medicare Rights Outlines Enhancements to Medicare Health Care Data

This week the Medicare Rights Center submitted a letter to the U.S. Senate Finance Committee in response to the Committee’s request for new ideas to improve the availability and transparency of health care data. In the letter Medicare Rights strongly supports recent efforts to increase health care data transparency, such as the release of provider utilization and payment data on Medicare physician services and the release of plan-reported data on multiple functions of Medicare Advantage (MA) and Part D plans, and provides input on opportunities to maximize the use of health care data within the Medicare program.

The letter details areas where the enhanced availability and accessibility of data has the potential to improve health care quality for people with Medicare. Recognizing the need for various data for different audiences, the letter distinguishes between data intended for researchers, advocates, policymakers, and regulators and data that is intended to facilitate beneficiary choice. Data enhancements intended for use by researchers, advocates, policymakers, and regulator include:

  • More plan-level data on Part D and MA operations
  • Centralized information on grievances and complaints
  • Comprehensive Medicare physician claims data
  • Enrollment data on Medicare low-income programs
  • And more…

For beneficiaries, Medicare Rights recommends the following:

  • Strengthen Plan Finder with MA network data and other streamlining
  • Improve the physician, supplier, and nursing home comparison tools
  • Provide centralized information on Medigap plans
  • Enhance information on health care quality
  • Make claims data available from a single source

According to Medicare Rights, improved access to the data described in the letter can serve to greatly enhance the quality of care delivered to Medicare beneficiaries and their families; however, increased access to data should not be a replacement for rigorous regulatory oversight. Medicare beneficiaries, independent researchers, and other stakeholders should not be expected to serve as de facto program watchdogs.

Click here to read the letter.

Report Finds Medicare Advantage Plans “Upcode” To Get Higher Rates

A recent Medicare and Medicaid Research Review (MMRR) report finds that many Medicare Advantage (MA) plans code in a way that makes beneficiaries enrolled in their plans seem sicker, resulting in higher payments from Medicare. Payments to MA plans are adjusted based on the risk score of each beneficiary, with higher risk scores resulting in larger payments to plans. This system was created to make sure that plans were properly paid for beneficiaries with higher needs. Yet, the study details methods used by MA plans to improperly inflate risk scores in order to get higher payments.

MA beneficiary risk scores are increasing at a much faster rate than Original Medicare beneficiaries’ risk scores, according to the MMRR report. MA enrollees, however, are generally healthier than Original Medicare beneficiaries, revealing that the difference in risk scores does not reflect increased needs among MA beneficiaries. According to the report, the most likely explanation for this difference is that the plans are inflating scores in order to receive higher payments—a practice known as upcoding. The report also finds that it is unlikely that these increased payments resulted in substantial health benefits to beneficiaries.

There are efforts underway at the Center for Medicare & Medicaid Services (CMS) to reign in the prevalence of upcoding. Additionally, the Affordable Care Act (ACA) set a goal to bring MA payments in line with Original Medicare costs. Most recently, CMS adjusted coding procedures to minimize the ability to utilize the categories most commonly used to upcode. Still, additional regulatory action is needed to limit the occurrence of upcoding.

Click here to read the MMRR report.

Volume 5, Issue 32

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Medicare Reminder

The coverage gap, also called the doughnut hole, is a phase of Part D prescription drug coverage during which the amount you pay for your prescription drugs increases. In the past, most people had to pay the full cost of their drugs in the coverage gap. Due to the Affordable Care Act, you no longer have to pay the full cost of your drugs during this period.

In 2014, the coverage gap starts when your total drug costs—including what you and your plan have paid for drugs—reaches $2,850. During the coverage gap, you pay 47.5 percent of the cost of brand-name drugs and 72 percent of the cost of generic drugs. You get out of the coverage gap when you have paid $4,550 out-of-pocket for covered drugs since the start of the year. The costs that help you get out of the coverage gap include what you spent on drugs, most of the discount on brand-name drugs that you received in the coverage gap, and the cost of drugs that someone else pays on your behalf (such as family members, most charities, or State Pharmaceutical Assistance Programs).

Click here to learn more about the coverage gap on Medicare Interactive.



Last week, Joe Baker, President of the Medicare Rights Center, wrote a letter to the editor of the Washington Post calling out certain beltway policy circles for continuing their unwarranted attacks on Medicare. The letter reads:

The Post argued that Medicare’s present success should spur Congress to pass “incremental reforms” that are preferable to unnamed “radical systemic change.” 

It seems that incremental is the new radical. Altering Medicare cost-sharing, as the editors suggested, saves money because, with higher upfront costs, beneficiaries living on fixed incomes are likely to forgo visits to doctors. Self-rationing because of cost is just as radical as imposed rationing.

While recent reports make clear that Medicare stands on stable financial footing, some in the Washington media continue to mislead the public, suggesting that Congress must slash benefits or hike costs for people with Medicare.

You can demand fair reporting on earned benefits by signing Medicare Rights’ latest petition.

Click here to read the letter to the Washington Post.


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