The scale and concentration of these overpayments underscores the structural coding advantage that the largest MA insurers hold, which shapes competitive dynamics and payment negotiations across the entire post-acute care sector.
For skilled nursing facilities, these findings matter because payer dominance in MA is not driven solely by efficient care delivery — it is also built on coding practices that generate billions in government subsidy.
Insurer-Level Estimates of Revenue From Differential Coding in Medicare Advantage
In 2021, the average MA risk score was 1.26; the average for a comparable group in TM was 1.07. The average MA risk score was 0.19 (95% CI, 0.17 to 0.21) higher than it would have been if MA coding patterns had been identical to coding in TM. MA plans received an estimated $33 billion in additional revenue attributable to differential coding, with $13.9 billion (42% of the total) going to UnitedHealth Group. There was wide variation in coding intensity across insurers; UnitedHealth Group’s risk score was 0.28 higher than TM, while Kaiser Permanente’s was only slightly higher.
— Annals of Internal Medicine, April 8, 2025
Kronick, Richard, et al. “Insurer-Level Estimates of Revenue From Differential Coding in Medicare Advantage.” Annals of Internal Medicine, 8 Apr. 2025. https://www.acpjournals.org/doi/10.7326/ANNALS-24-01345.
Medicare Advantage’s Diagnosing Tactics Made Insurers Like UnitedHealthGroup $33 Billion Richer
“The most important takeaway is that some Medicare Advantage insurers code much more aggressively than other insurers, and receive many billions of dollars in additional payment as a result,” [said] the study author, Richard Kronick, professor of family medicine at the Herbert Wertheim School of Public Health, University of California San Diego. “As a result, much of what determines which insurers are successful in Medicare Advantage is not whether the insurer is providing high quality care and doing so efficiently, but simply how aggressive it is in coding.”
— Fortune Well, April 9, 2025
Study Shows How UnitedHealth Uses Coding to Rake in Extra Cash From Medicare Advantage
Medicare Advantage insurers pulled in an estimated $33 billion in additional payment from the government in 2021 as a result of these extra diagnoses, or codes, that made their members seem sicker, relative to people in the traditional Medicare program. Almost $14 billion of that, or 42%, went to a single company: UnitedHealth, according to the research, published Monday in the Annals of Internal Medicine. Other insurers, like Humana and Aetna, comprised much smaller shares: 19% and 6%, respectively.
— STAT, April 7, 2025
✔ Comply with every payer's rules
✔ Equip your team with the Playbook
✔ Monitor rates and payer trends
