News & Analysis as of

Medicare Advantage Organizations (MAOs)

Morgan Lewis - Health Law Scan

CMS’s Delayed Final Rule on the FFS Adjuster Gets Delayed . . . Again

The Centers for Medicare & Medicaid Services (CMS) delayed the publication of the final rule on the use of extrapolation and the application of a fee-for-service adjuster (FFS Adjuster) in risk adjustment data validation...more

Faegre Drinker Biddle & Reath LLP

2023 Preventive Supplemental Benefit Landscape in Medicare Advantage: Insight Into A Competitive Market

Each year, the health plans that participate in the Medicare Advantage (MA) program compete vigorously for new members. Enrollment in the program has grown to over 28 million Americans, making 2023 a more competitive year...more

Ballard Spahr LLP

CMS Postponement of Medicare Advantage RADV Audit Rule Keeps Stakeholders Guessing

Ballard Spahr LLP on

Summary - On November 1, 2022, the Centers for Medicare and Medicaid Services (CMS) published notice that it will postpone for another three months the finalization of a methodology to audit Medicare Advantage (MA)...more

Sheppard Mullin Richter & Hampton LLP

CMS Pushes Publication of Final FFS Adjuster for RADV Audits Rule to February 1, 2023

CMS announced today a further extension until February 1, 2023, of the deadline for its publication of the long-awaited final rule on the use of extrapolation and the application of a fee-for-service adjuster (FFS Adjuster)...more

Robinson+Cole Health Law Diagnosis

Advisory Opinion 22-16: OIG Declines to Impose Sanctions for Arrangement Involving Provision of Gift Cards to Patients for...

On August 19, 2022, the Office of Inspector General (OIG) published Advisory Opinion 22-16 (Advisory Opinion) in which it declined to impose sanctions for an arrangement under which the requestor provides gift cards to...more

Epstein Becker & Green

OIG Approves Gift Cards for Medicare Managed Care Enrollees Who Complete Online Education

Epstein Becker & Green on

On August 19, 2022, the Department of Health and Human Services Office of Inspector General (“OIG”) posted Advisory Opinion 22-16 (“AO 22-16”) to its website, a favorable opinion concluding that the OIG would not impose...more

Ankura

Medicare Advantage Organizations' Denials of Some Prior Authorization Requests Raise Concerns

Ankura on

In the Office of the Inspector General's latest report released in April of 2022, the denials of some prior authorization requests by Medicare Advantage Organizations (MAOs) raise concerns about beneficiary access to...more

K&L Gates LLP

Health Care Triage: Medicare Advantage False Claims Act Developments

K&L Gates LLP on

In this episode, Stephen Bittinger and Nathan Huff discuss the growth of Medicare Part C (Medicare Advantage), new enforcements for Medicare Advantage Organization fraud, recent cases of False Claims Act liability, and key...more

Foley & Lardner LLP

Medicare Advantage: OIG Report Finds Improper Denials

Foley & Lardner LLP on

On April 27,2022, the Office of Inspector General of the Department of Health and Human Services (OIG), Office of Evaluations and Inspections, issued a report on the performance of Medicare Advantage Organizations (MAOs) in...more

Sheppard Mullin Richter & Hampton LLP

CMS Issues Contract Year 2023 Final Rule for Medicare Advantage Organizations and Prescription Drug Sponsors

On April 29, 2022, the Centers for Medicare and Medicaid Services (“CMS”), issued the final rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs...more

Sheppard Mullin Richter & Hampton LLP

HHS OIG Report On Prior Authorizations Under Medicare Advantage

Last month, the U.S. Department of Health and Human Services Office of Inspector (“OIG”) released a report that studied prior authorization denials and payment denials by Medicare Advantage Organizations (“MAOs”) (the...more

Skadden, Arps, Slate, Meagher & Flom LLP

DOJ-Initiated False Claims Act Activity on the Rise

Key Points The volume of new False Claims Act (FCA) case filings remained high in 2021, and the Department of Justice (DOJ) collected more than $5.6 billion in settlements and judgments — the second-largest annual total in...more

Thompson Coburn LLP

DOJ and OIG ramp up enforcement of risk adjustment coding: 5 compliance tips for providers

Thompson Coburn LLP on

Medicare Advantage plans and providers need to be aware of the recent increase in government enforcement of risk adjustment coding issues. In the past few years, the Office of the Inspector General (OIG) and the Department of...more

Mintz - Health Care Viewpoints

CMS Proposes Changes to Medicare Advantage Regulations: Network Adequacy, Beneficiary Access, MLR Reporting, and MOOP

Continuing our series analyzing the recently proposed Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs rules (Proposed Rule), this post focuses on a few...more

Sheppard Mullin Richter & Hampton LLP

CMS’s Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs

On January 6, 2022, the Centers for Medicare and Medicaid Services (“CMS”) issued the proposed rule on Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs...more

Polsinelli

As DOJ Focuses on Medicare Advantage Reimbursement, So Should Health Care Providers

Polsinelli on

Over the past year, the federal government has taken concrete steps to fulfill its promise of a heightened commitment to investigating and enforcing health care fraud within the Medicare Advantage program (Medicare Part C). ...more

Bradley Arant Boult Cummings LLP

D.C. Circuit Ruling Escalates False Claims Act Risk for Medicare Advantage Organizations

In a ruling that may portend a significant uptick in False Claims Act (FCA) whistleblower cases, last week the U.S. Court of Appeals for the District of Columbia Circuit reversed a 2018 decision that vacated Medicare's...more

Sheppard Mullin Richter & Hampton LLP

D.C. Circuit Gives New Life to CMS Overpayment Rule

On August 13, 2021, the D.C. Circuit Court of Appeals reversed a district court opinion vacating CMS’ Overpayment Rule, 42 C.F.R. 422.326, for Medicare Advantage organizations (“MAOs”). UnitedHealthcare Insurance Co. et al....more

Manatt, Phelps & Phillips, LLP

Interoperability and Transparency Rules Usher in a New Era of Health Plan Data Obligations

After a six-month delay due to the COVID-19 pandemic, the first provisions of the interoperability rule issued by the Centers for Medicare & Medicaid Services (CMS) took effect on July 1. The new requirements are the first of...more

Wiley Rein LLP

[Webinar] Adjusting the Risk for Medicare Advantage: Recent Enforcement Trends and Litigation Involving Medicare Advantage Risk...

Wiley Rein LLP on

The Department of Justice (DOJ) continues to concentrate on risk adjustment programs of payers with Medicare Advantage Organizations (MAO) as a prime enforcement target. One particular area of focus, both civilly and...more

Husch Blackwell LLP

Hospice Audit Series: The Latest Developments and Strategies for Success in the Ever-changing Audit Landscape

Husch Blackwell LLP on

Hospice Audits Series Audits are a fact of life for hospices—it’s not a matter of “if” a hospice will be audited, but “when.” The alphabet soup of audits has expanded, from UPICs to SMRCs, CPIs, TPEs and more. With the...more

Bass, Berry & Sims PLC

Healthcare Fraud & Abuse Review 2020

Ensuring compliance with the False Claims Act has never been more important for healthcare providers. By March 2020, we saw healthcare professionals standing at the forefront of one of the greatest health crises in a...more

ArentFox Schiff

11th Circuit Upholds Rights of Medicare Advantage ‘Downstream Actors’ to File Suit under the Medicare Secondary Payer Act

ArentFox Schiff on

Calling it a “straightforward inquiry,” the US Court of Appeals for the 11th Circuit recently opted to expand access to the Medicare Secondary Payer Act (the MSP Act) private right of recovery to Medicare Advantage...more

Health Care Compliance Association (HCCA)

OIG report: Payment of $2.6 billion to Medicare Advantage plans raises concerns

Compliance Today (November 2020) - The U.S. Department of Health & Human Services Office of Inspector General (OIG) September 2020 report titled Billions in Estimated Medicare Advantage Payments From Diagnoses Reported...more

Verrill

Hospital Price Transparency Rule: Full Steam Ahead

Verrill on

Neither COVID-19 nor continued legal challenges appear likely to derail the Centers for Medicare & Medicaid Services (CMS) Hospital Price Transparency Rule from going into effect on January 1, 2021. Hospitals therefore should...more

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