For post-acute providers, SNFs should anticipate payers to adapt to tightening margins as the government moves to recoup inflated payments.
Chart Reviews Increase Payments to Medicare Advantage Insurers for 1 in 6 Enrollees
More than 6 in 10 (62%) of Medicare Advantage enrollees — approximately 18 million people — had at least one chart review record in 2022. One in six (17%) Medicare Advantage enrollees had diagnoses added through chart reviews that increased federal payments but did not appear in encounter records submitted by providers. Among the 18 million enrollees with chart review records, about 30% had diagnoses added that increased federal payments, while just over 1% had diagnoses removed. Eight conditions added from chart reviews contributed at least $1 billion each to Medicare payments, including vascular disease, COPD, diabetes with complications, and congestive heart failure. Chart reviews resulted in an estimated $24 billion in additional MA payments in 2023.
— KFF, November 20, 2025
Fuglesten Biniek, Jeannie et al. “Chart Reviews Increase Payments to Medicare Advantage Insurers for 1 in 6 Enrollees.” KFF, 20 Nov. 2025. https://www.kff.org/medicare/chart-reviews-increase-payments-to-medicare-advantage-insurers-for-1-in-6-enrollees/.
Chart Reviews Boost Medicare Advantage Payments: 4 Things to Know
Insurers carry out chart reviews to verify alignment between medical records and information submitted by providers. While these reviews can help payers understand a beneficiary’s needs and increase payments to accommodate anticipated costs, they could also be used inappropriately. “Chart reviews can also identify diagnoses that are inaccurate, no longer an active consideration or unrelated to the clinical care enrollees receive, and thus potentially inappropriate to submit to CMS for payment purposes,” a Nov. 20 KFF report said.
— Becker’s Payer Issues, November 20, 2025
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
