Chart Reviews Boosted Payments for 1 in 6 MA Members
A new analysis from KFF sheds fresh light on one of the most debated practices in Medicare Advantage (MA): the use of chart reviews to identify additional diagnoses that increase federal payments to plans. The findings are significant, and they highlight both the structural incentives built into the MA payment system and the ongoing scrutiny the industry faces from CMS, MedPAC, and Congress.
According to KFF, 1 in 6 Medicare Advantage enrollees (17%) had a new diagnosis added through a chart review in 2022 that increased federal payments to their MA plan. By contrast, less than 1% had a diagnosis removed—a striking imbalance that illustrates the financial direction of documentation-based adjustments.
The analysis goes further: six in ten (62%) MA enrollees had at least one chart review record in their 2022 encounter data. In other words, chart reviews are not occasional audits or edge processes—they are now deeply embedded in the operating fabric of Medicare Advantage risk adjustment.
Why Chart Reviews Matter So Much in Medicare Advantage
Chart reviews are conducted by MA insurers to reconcile and validate clinical information from providers. Ideally, they ensure that a member’s documented conditions accurately reflect their true disease burden and care needs. But in practice, the distinction between validation and revenue optimization can become blurred.
Under the HCC risk adjustment coding model, MA plans receive higher payments for beneficiaries with more diagnosed conditions. Correctly identifying and coding legitimate conditions ensures adequate reimbursement and supports population health management. But the system may unintentionally incentivize insurers to aggressively pursue documentation gaps—especially through retrospective chart reviews that may uncover (or in some cases infer) conditions not captured during face-to-face visits.
Traditional Medicare does not use chart reviews for payment adjustments, which has fueled concerns that MA plans are being compensated based on documentation rather than differences in patient acuity.
KFF’s findings reinforce what MedPAC and OIG have signaled for years: chart reviews are one of the largest contributors to excess payments in MA, and the financial impact is enormous.
The Cost: $24 Billion in Additional Payments in 2023
MedPAC estimates that chart reviews and related coding intensity practices led to $24 billion in additional payments to Medicare Advantage plans in 2023 alone. While a significant portion of these payments may be appropriate, they are one of the most significant drivers of higher federal spending in the MA program.
Lawmakers on both sides of the aisle have raised concerns about:
Coding intensity compared to Traditional Medicare
Revenue dependence on retrospective chart audits
Documentation inflation or “upcoding” pressures
Limited oversight of how added diagnoses map to real care delivery
The KFF report arrives amid multiple policy proposals to reform how MA risk scores are calculated. CMS has already phased in the V28 CMS-HCC model—which removed thousands of codes, narrowed diagnostic specificity, and rebalanced condition weights—to reduce coding variation and tighten compliance. Congress is exploring additional mechanisms to close payment loopholes, require more encounter-based documentation, and potentially limit the role of chart reviews altogether.
What This Means for Medicare Advantage Plans, Providers, and Risk-Bearing Entities
The takeaway is clear: the days of lenient chart-review-driven revenue are numbered.
MA plans and delegated provider groups now face simultaneous pressures:
Stricter audit environments, including RADV extrapolation
Tighter documentation rules under CMS-HCC V28
Growing political scrutiny of coding-driven revenue
Operational burdens on providers required to validate more complex documentation
Yet the underlying problem persists: providers still struggle with documentation completeness, coding accuracy, and the sheer administrative burden of pre-visit chart review—especially for complex Medicare Advantage patients.
In this environment, relying solely on manual workflows or retrospective chart reviews is no longer financially safe or operationally sustainable.
A Modern Approach: Real-Time, Evidence-Based Risk Adjustment
As the industry shifts toward real-time, encounter-based accuracy, the organizations that will thrive are those adopting AI-powered, prospective, point-of-care documentation intelligence—not those doubling down on retrospective coding cleanup. This is where ForeSee Medical can help.
ForeSee Medical’s AI-powered risk adjustment software delivers real-time HCC insights, condition validation, and documentation support directly from EHR data—before the visit, during the encounter, and without the compliance risks associated with retrospective chart reviews.
By using advanced NLP, machine learning, and medical evidence mapping like InstaVu, ForeSee helps providers accurately capture the patient's true disease burden while reducing coding burden and improving audit readiness.
As chart review scrutiny intensifies, accuracy, integrity, and real-time insights will define success in Medicare Advantage.
If your organization is preparing for the future of compliant, encounter-based risk adjustment, ForeSee Medical can help you get there—faster, safer, and with better results.
Blog by: The ForeSee Medical Team