Medicare Advantage (Part C)
Medicare Advantage is an alternative to Traditional Medicare administered by private insurers who receive per-member-per-month capitated payments from CMS, covering 32 million+ beneficiaries — more than half of the entire Medicare population as of 2024.
What is Medicare Advantage?
Medicare Advantage (MA), also known as Part C, allows private insurers to administer Medicare benefits in exchange for a risk-adjusted, per-member-per-month (PMPM) capitated payment from CMS. Plans must cover all Medicare Part A and B benefits and often offer additional benefits (dental, vision, OTC allowances). CMS Star Ratings (1–5 stars) directly affect plan bonus payments: 5-star plans receive a 5% bonus on their benchmark payment and can market year-round outside the annual election period, while plans below 3 stars face enrollment restrictions. Risk adjustment through Hierarchical Condition Categories (HCC) coding means MA plans — and their contracted providers — are paid more for sicker patients, creating strong financial incentives for thorough diagnosis documentation during every encounter. RADV (Risk Adjustment Data Validation) audits are CMS's mechanism to recover overpayments when submitted diagnoses are not supported in the medical record. MA plans also impose prior authorization requirements for services that Traditional Medicare does not, with 35 million+ prior auth requests annually across MA plans.
Why It Matters for Healthcare Analytics
As MA penetration exceeds 50% of Medicare, practices must track MA vs. Traditional Medicare reimbursement rates, prior auth approval and denial rates by plan, AWV completion rates (MA plans often provide financial incentives), and HCC capture rates per patient per year. A single missed HCC diagnosis can cost a practice $1,000–3,000 in risk-adjusted revenue annually per patient.
How Vizier Tracks Medicare Advantage
Upload your payer data and ask "What is our prior auth denial rate by Medicare Advantage plan this quarter?" — Vizier segments performance by plan, identifies high-denial payers, and surfaces HCC documentation gaps across your attributed patient panel.