News & Analysis as of

Medicare Advantage

Second DOJ Complaint: Knowledge of Invalid Codes Requires Follow-Through to Avoid Liability

by Bass, Berry & Sims PLC on

The DOJ’s recent complaint-in-intervention in US ex rel. Poehling v. United Health Group — one of two qui tam cases against United Health currently pending in the Central District of California — emphasizes the government’s...more

Exaggerated Diagnosis Codes and Inadequate Provider Networks: Allegations of Medicare Advantage Fraud Settled for $32.5 Million

by BakerHostetler on

The latest settlement involving Medicare Advantage (MA) organizations highlights not only the government’s continuing enforcement focus on Medicare Part C but also the vulnerabilities inherent in that program. In United...more

DOJ’s New Healthcare Fraud Target—Medicare Advantage Insurers

by Blank Rome LLP on

The government continues to seek ways to rein in healthcare costs. Now it has set its sights on the Medicare Advantage Program. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private...more

The Enforcement Risks for Medicare Advantage Plans Continue: A New False Claims Act Settlement in Florida

Recent activities of the Department of Justice (“DOJ”) and Qui Tam whistleblowers reveal that Medicare Advantage Plans remain at the forefront of investigations for violations of the federal False Claim Act (“FCA”) for...more

Proposed Telehealth Expansion of Medicare Reimbursement

by Baker Ober Health Law on

Telehealth continues to be a frontrunner on one strategy to achieve the triple aim, an effort to improve patient experience, population health and reduce per capita cost. To date, government reimbursement for telehealth...more

Healthcare Weekly Preview from ML Strategies – June 2017

Welcome back everybody. With Congress returning from recess, we should expect an update on the progress of the Senate-version of the American Health Care Act. Despite the noise from GOP members about a timeline, one thing...more

An Unsettling Settlement: Health Plan to Pay $32 Million to Settle Coding and Provider Network Misrepresentation Charge

by Faegre Baker Daniels on

On May 30, the Department of Justice (DOJ) announced that it reached a settlement with commonly-owned Freedom Health Inc. and Optimum Healthcare, Inc. (Freedom Health) — two Tampa, Florida, managed care plans — to settle...more

CBO Greenlights Telehealth Provisions in Senate’s CHRONIC Care Act

Last week, the Congressional Budget Office (CBO) concluded that a key piece of telehealth legislation, the CHRONIC Care Act of 2017, would not, overall, increase or decrease Medicare spending. This score is significant as it...more

Medicare Advantage Plans Under Fire: The Department of Justice Files Complaints-in-Intervention

As reported in earlier blogs, the federal Department of Justice (DOJ) has been actively looking into potential abuses by Medicare Advantage (MA) Organizations as to allegedly improper risk adjustment claims submissions and...more

Health Care E-Note - May 2017

by Burr & Forman on

When a physician leaves a medical practice, especially if the physician stays in the area to compete against his/her former employer, the situation can become stressful and acrimonious. Please see full E-Note below for...more

CY 2018 Medicare Advantage Final Call Letter

The most recent MA Call Letter, “Announcement of Calendar Year (CY) 2018 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter and Request for Information” (Call Letter)...more

Medicare Advantage 2018 Rate Announcement

The Centers for Medicare and Medicaid Services (CMS) announced its 2018 Medicare Advantage (MA) capitation rates, with an expected increase of .45 percent, slightly higher than proposed in the advance notice. CMS estimates...more

CMS Finalizes 2018 Medicare Advantage/Part D Policies, Seeks Ideas for Improving Programs

by Reed Smith on

CMS has released its 2018 Medicare Advantage (MA) and Part D Rate Announcement and Call Letter. CMS estimates that plan revenues will increase by 0.45 percent in 2018; when coding acuity is considered, plans can expect a...more

Calling for Ideas—CMS Releases Final 2018 Medicare Advantage and Part D Rate Announcement and Call Letter

by Hogan Lovells on

On 3 April 2017, the Centers for Medicare & Medicaid Services (CMS) released its final Medicare Advantage (MA) and Part D Rate Announcement and Call Letter (Call Letter) for calendar year 2018. The Call Letter is part of...more

Final Policies on Encounter Data and the Star Ratings Released

by McDermott Will & Emery on

The Centers for Medicare and Medicaid Services recently finalized meaningful Medicare Advantage policy changes in response to industry concerns, including those regarding data integrity, the Star Ratings and encounter data....more

CMS Reconsiders Its Position Prohibiting Quota Share Reinsurance For Medicare Advantage Organizations

by Locke Lord LLP on

We previously reported on February 13, 2017 that the Centers for Medicare & Medicaid Services (CMS), on February 1, 2017, in connection with its 2018 Advance Notice (Notice), advised that quota share reinsurance arrangements...more

The Siege Continues: The Justice Department is Investigating Four Additional Medicare Advantage Plans

In our prior blog post, we reported that, at the request of the federal Department of Justice, the FCA qui tam whistleblower lawsuit in the case of United States ex rel Benjamin Poehling v. United HealthGroup, Inc., et. al....more

The Siege Continues: The Justice Department Is Investigating Four Additional Medicare Advantage Plans On Risk Adjustment Issues

WHO IS AT RISK - The federal government has indicated that it is still investigating, and could ultimately join a false claims whistleblower qui tam action against Aetna, Inc., Humana, Inc., Cigna, Inc. (through its Bravo...more

DOJ Issues New Guidance on the Evaluation of Corporate Compliance Programs in Federal Fraud Investigations

On February 8th, the U.S. Department of Justice (DOJ) quietly issued new guidance on how the agency evaluates corporate compliance programs during fraud investigations. The guidance, published on the agency’s website as the...more

DOJ Intervenes in Risk Adjustment FCA Case

by Bass, Berry & Sims PLC on

Recently, the DOJ intervened in one of several currently pending qui tam cases involving Medicare Advantage (MA) and the Risk Adjustment process used to determine the amount of payments to Medicare Advantage Organizations...more

Medicare Advantage Plans Under Siege: Another Whistleblower Lawsuit

In a court decision last year in Swoben v. United Healthcare, the United States Court of Appeals for the Ninth Circuit held that an allegation – that a Medicare Advantage Plan performed a “biased” HCC-RAF retrospective...more

CMS Releases Proposed 2018 Medicare Advantage/Part D Reimbursement Methodologies and Policies

by Reed Smith on

CMS has released its 2018 Advance Notice and Call Letter, which outline proposed updates to Medicare Advantage (MA) and Part D plan reimbursement methodologies and policies. CMS notes that it its proposed policies focus on...more

DOJ Successfully Blocks Insurance Mergers: What Are the Takeaways?

In July 2016, following a lengthy review, the Antitrust Division of the Department of Justice (DOJ), together with several states, sued to block two proposed health insurer mergers: Aetna/Humana and Anthem/Cigna. On January...more

Justice Department Joins Whistleblower Suit Accusing UnitedHealth Group of Overcharging Medicare by “Hundreds of Millions”

The U.S. Department of Justice (DOJ) has joined a whistleblower lawsuit, United States of America ex rel Benjamin Poehling v. Unitedhealth Group Inc., No. 16-08697 (Cent. Dist. Cal. Sep. 17, 2010), ECF No. 79, against...more

Health Update - February 2017

Securing the Safety Net for America's Vulnerable Populations - Editor's Note: America's population is aging rapidly. By 2029, 75 million baby boomers will have reached age 65 and older, and older adults will represent...more

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