The potential for gaming the ACA exchanges
The Affordable Care Act created a program called risk adjustment to help steer funding from health insurance companies with healthier customers to companies that attract sicker people. But an FBI investigation into allegations that Oregon-based health care system Zoom fraudulently tinkered with the codes and medical claims of its insurance customers is causing concern that the program is ripe for widespread gaming.
The takeaway: Many experts believe Zoom likely is an aberration in the ACA marketplaces. But risk adjustment has a history of abuse, particularly in Medicare Advantage.