The Centers for Medicare & Medicaid Services (CMS) has recently unveiled the Calendar Year (CY) 2025 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates, as well as for Part C and Part D Payment Policies.
Stakeholders and interested parties are invited to submit their comments on the proposed changes until 6 o’clock p.m. Eastern Time on Friday, March 1, 2024, before CMS finalizes the Rate Announcement by April 1, 2024.
Medicare Advantage, a cornerstone of the Medicare program, offers beneficiaries an alternative to the traditional Medicare fee-for-service (FFS) model available through private plans. These plans are reimbursed by CMS through a capitation model, which pays a fixed amount per enrollee, making the accurate and fair setting of these rates critical to the program’s health and sustainability. The CMS is tasked with yearly updates to these payment rates, incorporating technical adjustments aimed at maintaining the accuracy and relevance of the MA payments.
The CY 2025 Advance Notice proposes several methodological changes that, if finalized, are anticipated to yield a net increase in MA payments to plans. This development is significant, suggesting a positive outlook for plans and potentially for beneficiaries in terms of available services and coverage options. The proposed updates take into account several factors, including the effective growth rate, changes in star ratings, MA coding pattern adjustments, risk model revisions, and the MA risk score trend. Together, these factors contribute to an expected average revenue change of +3.70 percent for MA plans in CY 2025.
A closer look at the individual components reveals a nuanced picture of the proposed changes:
An increase of 2.44 percent signals optimism about the growth and stability of the Medicare Advantage market. This rate reflects broader economic trends and healthcare cost projections, indicating a healthy trajectory for the program.
Yet to be determined (TBD), this factor is crucial for aligning payment rates with current healthcare costs and economic conditions, ensuring that MA plans are adequately compensated for the services they provide to beneficiaries.
A slight decrease of -0.15 percent in this area suggests adjustments in how plan quality is measured and rewarded. Star ratings are a key component of how CMS evaluates plan performance, impacting payments through quality bonus payments.
Set at 0 percent, indicating no change in the adjustment factor that accounts for differences in diagnosis coding patterns between MA plans and traditional Medicare.
A significant negative adjustment of -2.45 percent reflects updates to the risk adjustment model and efforts to normalize payments between MA and traditional FFS Medicare, ensuring equity and accuracy in compensation for the care of beneficiaries.
An increase of 3.86% in this area suggests that MA plans are expected to manage a population with increasing health risks, necessitating higher payments to accommodate the greater needs of these beneficiaries.
Additionally, the Advance Notice proposes updates to reflect the Part D redesign mandated by the Inflation Reduction Act, signaling significant changes in how prescription drug benefits are structured and financed within the Medicare Advantage and Part D ecosystems. Stakeholders are encouraged to engage in the comment process, contributing to the refinement and finalization of these policies. As the healthcare landscape continues to evolve, such updates are essential for maintaining the balance between adequate plan compensation, beneficiary affordability, and program sustainability.
Literature is ripe with classic phrases that seem timelessly apropos. For example, take the partial federal government shutdown. For days, the phrase repeated in the
While underdosing is no longer a new concept in coding it remains a common area of confusion. Underdosing is when a patient takes less of
Please log in to your account to comment on this article.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
Copyright © 2025 ICD10monitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
