ACOs Denying Access to Medicare Advantage Patients:
Primary Care Physician (PCP) Practices or companies that encourage and promote claiming an exaggerated level of severity of a beneficiary's (or patient's) medical condition. The higher the documented severity the higher the ACO Medicare Advantage capitated rates from Medicare. This occurs when the Medicare beneficiary enrolls in a ACO Medicare Advantage health insurance plan sponsored by private insurance companies. The less the patient uses medical services, the more money the PCP makes. Hence the scheme involves the PCP denying the patient access to specialists services in order to keep the actual costs low. The PCP is paid a capitated rate based on the foreseen risk of the patient, but the PCP denies access to the patient in order to keep the costs low and the profitability high.
