News & Analysis as of

Medicare Advantage

Federal Court Strikes DOJ's Risk Adjustment False Claims Act Case - For Now

by Pepper Hamilton LLP on

On October 5, a federal district court in California dealt a significant setback to the government’s efforts to extend False Claims Act (FCA) liability to Medicare risk adjustment submissions....more

Dismissal of Medicare Advantage FCA Suit Marks Significant Defeat for Government

by Bass, Berry & Sims PLC on

The U.S. District Court for the Central District of California recently dismissed a complaint-in-intervention filed by the U.S. Department of Justice (DOJ) in U.S. ex rel. Swoben v. Secure Horizons. As previously reported,...more

False Claims Act Watch: California Federal Judge Dismisses DOJ Complaint Alleging Medicare Advantage Fraud

by Kelley Drye & Warren LLP on

On October 5, the U.S. Department of Justice suffered a setback when a California federal judge dismissed its complaint under the civil False Claims Act (“FCA”). Billed as a test case for the Government, it marked the first...more

Chronic Care Legislation Approved by Senate

by Reed Smith on

The U.S. Senate has unanimously approved S. 870, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 (as amended). The bill is intended to improve care for the chronically...more

Alert: In a Surprise Decision Issued on October 5, 2017, Honorable John Walter, United States District Judge, Dismissed a Medicare...

On October 5, 2017, the Honorable Judge John Walter of the United States District Court, Central District of California, granted the Defendants’ Motion to Dismiss the Medicare Advantage (“MA”) Federal False Claims Act (“FCA”)...more

Managed Care Quarterly Review: Issue 1

by McGuireWoods LLP on

Tips for Managing Large Claims Disputes Part 1: Pre-Litigation Avoidance and Early Litigation Strategies - Large claims disputes brought by providers against payers are on the rise. Based on previous experience with dozens...more

In Removing HSD Tables From Applications, CMS Opens the Door to Medicare Advantage Growth

by Faegre Baker Daniels on

Recently, the Centers for Medicare & Medicaid Services (CMS) released its draft 2019 Medicare Advantage application. Health plans seeking to participate in the Medicare Advantage (MA) program for the first time or expanding...more

Double Whammy for United Healthcare: Two False Claims Act Cases in Two Weeks

by Michael Volkov on

The False Claims Act is the government’s weapon of choice in fighting healthcare fraud. In the beginning of the Obama Administration, Congress amended the False Claims Act and enacted a wish list from DOJ prosecutors. ...more

Client Alert: Feds Shine a Light on Medicare Advantage Plans and Physicians Related to Risk Adjustment Practices

Although the sufficiency of medical records documentation supporting beneficiary diagnoses for Medicare Advantage (MA) risk adjustment has been on the OIG’s work plan since 2013, the Department of Justice has upped the ante...more

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

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