Medicare Advantage

News & Analysis as of

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

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

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

A tale of two mergers: Following their losses in DOJ merger challenges, Anthem fights on and Aetna gives up

In the past month, the DOJ and several state governments scored two trial wins in their challenges to mergers among some of the country’s largest health insurers. First, Judge Bates of the District of Columbia blocked the...more

HHS Finalizes Appeals Backlog Rule in Wake of Judicial Order

The U.S. Department of Health and Human Services (HHS) released a Final Rule aimed at reducing and eventually eliminating the backlog of more than 650,000 claims currently awaiting adjudication by an administrative law judge...more

CMS’s Draft 2018 Call Letter: Minor Updates, but Largely a Continuation of Current Policies

Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released its 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter (“Draft Call Letter”). For the majority of the letter’s provisions,...more

CMS: Quota share reinsurance

In an abrupt change in position, the US Centers for Medicare & Medicaid Services ("CMS"), in its Advance Notice of Methodological Changes for Calendar Year (CY) 2018, the "Call Letter", published February 1, 2017, announced,...more

"DOJ Continues Streak of Successful Merger Challenges With Blocked Aetna-Humana, Anthem-Cigna Deals"

In a continuation of recent Department of Justice (DOJ) successes challenging mergers, the U.S. District Court for the District of Columbia recently enjoined two more proposed mergers brought and litigated under the Obama...more

No Quota Share Reinsurance For Medicare Advantage Organizations, Says CMS

On February 1, 2017, the Centers for Medicare & Medicaid Services (CMS), in connection with its 2018 Advance Notice (the Notice), advised that quota share reinsurance arrangements are not a statutorily permitted form of...more

Medicare Advantage Draft Call Letter Addresses Encounter Data, Star Ratings

On February 1, 2017, the Centers for Medicare & Medicaid Services (CMS) released proposed updates to the Medicare Advantage (MA) and Part D programs through the CY 2018 Advance Notice and Draft Call Letter. Despite largely...more

Aetna-Humana Merger Blocked

The District of Columbia federal court recently ruled that a proposed $37 billion merger between health insurance giants Aetna and Humana cannot proceed, granting the US Department of Justice’s bid to block the combination on...more

CMS Report Blasts Provider Directory Errors

A new report by CMS echoes many patients in criticizing Medicare Advantage (MA) online provider directories for containing too many errors. “Online Provider Directory Review Report” concludes that too often a directory entry...more

21st Century Cures: A Closer Look

On December 7, 2016, the US Congress enacted the 21st Century Cures Act, substantial legislation intended to accelerate “discovery, development and delivery” of medical therapies by encouraging biomedical research investment,...more

OIG Rings in the New Year With New Anti-Kickback Statute Safe Harbors

Just in time for the New Year, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services issued final regulations (Final Regulations) that revised two existing Anti-Kickback Statute safe...more

The Old and the New – Day 3 Notes from the JPMorgan Healthcare Conference

Day 3 of the JPMorgan healthcare conference was one of striking contrasts between the old and the new. (And, by the way, the rain finally stopped for a day, but it will be back tomorrow to finish off the last day of the...more

Looking Forward/Looking Backward – Day 1 Notes from the JPMorgan Healthcare Conference

A large amount of wind, much discussion about the U.S healthcare, and the public getting soaked again – if you were thinking about Washington, DC and the new Congress, you’re 3,000 miles away from the action. This is the week...more

HHS OIG Expands Anti-Kickback Safe Harbors and Civil Monetary Penalties Law Exceptions; Issues Guidance on Gifts of Nominal Value

On December 7, 2016, the Office of Inspector General (the “OIG”) of the U.S. Department of Health and Human Services (“HHS”) issued a final rule modifying the safe harbors to the anti-kickback statute1 and the civi monetary...more

OIG Finalizes New and Amended Anti-Kickback and CMP Safe Harbors

On December 7, 2016, the Department of Health and Human Services Office of the Inspector General (OIG) issued a final rule to establish new safe harbors under the anti-kickback statute and civil monetary penalty (CMP) rules,...more

OIG Finalizes CMP Regulations, Largely as Proposed

On December 7, 2016, the Department of Health and Human Services, Office of Inspector General (OIG) finalized [PDF] its proposal to update the civil monetary penalty (CMP) regulations – namely, incorporate new CMP authorities...more

The ERISA Litigation Newsletter - December 2016

This month Richard Zall, Chair of Proskauer's Health Care Department, explores developments likely to occur with respect to the Affordable Care Act as a result of the new administration. In our Rulings, Filings and...more

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