Medicare billing practices have come under increased scrutiny, raising important questions about risk-adjusted payments, fraud, and inefficiencies in the system. Anomaly CEO Mike Desjadon recently joined CNBC’s The Exchange with Kelly Evans to shed light on these complexities and discuss how AI-driven solutions can help improve transparency and efficiency in healthcare payments.
In the interview, Desjadon explained the concept of risk adjustment in Medicare. Essentially, risk adjustment involves assessing a patient’s diagnoses to determine their expected healthcare costs.
“The analogy I give is hiring an attorney to find every tax loophole to minimize tax liability,” said Desjadon. “It’s not fraud, it’s not illegal—it’s just that some organizations are particularly good at leveraging the system.”
This is where abuse comes into play. If a diagnosis is recorded but not treated, should it justify increased Medicare payments? Desjadon emphasized that this discrepancy is central to the ongoing scrutiny of billing practices.
Medicare Advantage (MA) was designed to lower overall Medicare costs, but according to recent reports, it may be doing the opposite. Desjadon cited a report from the Congressional Payment Advisory Committee stating that Medicare Advantage overpaid by 22%—amounting to $83 billion last year alone. If left unchecked, this could reach $1 trillion in the next decade.
“The goal of Medicare Advantage is to lower expenditures, but it just isn’t working right now,” Desjadon stated. With Medicare Advantage now covering 54% of Medicare-eligible individuals, and that number projected to rise, the financial stakes are enormous.
A major concern is that the incentives in Medicare Advantage may encourage health plans to diagnose patients as sicker than they are, leading to higher reimbursement rates. Desjadon stressed the need for better oversight and data transparency to ensure Medicare funds are allocated appropriately.
As Medicare spending grows, it becomes increasingly important to analyze where the money is going. Desjadon highlighted that Anomaly’s AI-driven technology helps health systems monitor whether Medicare Advantage is reimbursing providers fairly compared to traditional Medicare.
“We don’t work with the government; we work on behalf of health systems,” he noted. “But even in our own business, we’re constantly asked to track if Medicare Advantage is paying what it’s supposed to—because often, it doesn’t.”
By leveraging AI and data analytics, Anomaly and similar companies are helping health systems detect improper payments and reduce financial inefficiencies. As Desjadon pointed out, the healthcare industry must do more to ensure that Medicare and Medicare Advantage payments align with actual patient care needs.
Desjadon’s key takeaway? Medicare’s billing system requires stronger oversight and more advanced analytical tools to prevent financial mismanagement. With Medicare Advantage set to grow and an aging population requiring more care, now is the time to ensure funds are being spent wisely.
As healthcare costs rise, AI-powered solutions like Anomaly’s will play a crucial role in holding payers accountable and ensuring that the Medicare system remains sustainable for future generations.
