Business Better Podcast Episode: 2024 Advance Notice: Proposed Changes to the Medicare Advantage Risk Adjustment Model
When I investigated and litigated False Claims Act (FCA) cases at the U.S. Department of Justice (DOJ) over the last 10 years, I was often surprised by just how little I knew about the broad array of government agencies and...more
WHERE VALUE-BASED CARE MEETS THE BUSINESS OF HEALTHCARE - Join hundreds of c-suite leaders, investors, operators and counsel in the healthcare capital of the United States for a deep dive into the key business and policy...more
On April 1st, the Centers for Medicare & Medicaid Services (“CMS”) announced its Medicare Advantage (“MA”) Capitation Rates and Part C and Part D Payment Policies for Calendar Year (“CY”) 2025. This announcement builds on the...more
ACI’s Advanced Forum on Managed Care Disputes and Litigation offers an unparalleled learning experience, specifically designed for the MCO legal community. Attend and develop winning legal strategies and business best...more
In an indictment announced on October 26, 2023 in Miami, the U.S. Department of Justice, Criminal Division’s Fraud Section, working with the FBI and HHS-OIG, brought what may be only the second federal criminal charges...more
Learning Objectives - Review Proposed Changes for Medicare Advantage Plans in 2024 - Discuss the change from Version 24 to Version 28 and the impact on Risk Adjustment Calculation Methodology - Explain how...more
McDermott Will & Emery Partner Ankur Goel moderated a panel during the Value-Based Care Symposium that focused on the risk-adjustment landscape and provided insights into how the regulatory environment and contractual...more
In this episode, we discuss the Centers for Medicare and Medicaid Services’ proposed changes to the Medicare Advantage risk adjustment payment model, which will take effect in 2024 if finalized. We’re joined by special guest...more
More than four years after it was proposed, on February 1, 2023 the Centers for Medicare & Medicaid Services (CMS) published the long-awaited risk adjustment data validation (RADV) Final Rule (Final Rule) that will affect...more
The Centers for Medicare and Medicaid Services (CMS) published its final rule regarding the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program in early February 2023. Among other matters, the final rule...more
The Centers for Medicare & Medicaid Services (CMS) was very busy last week! On Jan. 30, CMS issued its long-awaited Risk Adjustment Data Validation (RADV) Final Rule....more
On January 30, 2023, CMS posted for inspection a final rule describing its Risk Adjustment Data Validation audit methodology (the Final RADV Rule). As we have discussed in prior alerts, the finalization of the RADV Rule,...more
Addressing a recent motion to dismiss, the Northern District of California predominantly denied Kaiser Permanente’s (“Kaiser”) motion to dismiss the government’s complaint in United States ex rel. Osinek v. Permanente Medical...more
Courts are grappling with unique questions in the context of managed care programs in False Claims Act (FCA) cases. But are they getting it right? Two questions trending in courts relate to: (1) materiality under the FCA when...more
The Fifth Circuit Court of Appeals recently rejected a slew of claims by Vista Health Plan, Inc. (“Vista”) seeking to invalidate the 2017 and 2018 regulations governing the risk adjustment program that applies to individual...more
Various smaller health insurance issuers have challenged the risk-adjustment program under the Patient Protection and Affordable Care Act (ACA), alleging, among other things, that its underlying methodology favors larger...more
On September 20, 2021 the Office of the Inspector General of the U.S. Department of Health and Human Services (OIG) issued a report suggesting that certain Medicare Advantage (MA) companies were leveraging chart reviews and...more
A major California-based health care system, Sutter Health, and several of its medical practice foundation affiliates have agreed to pay a total of $90 million to settle allegations that they violated the False Claims Act...more
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
The Biden Administration used the annual rulemaking that governs health plans sold on the Affordable Care Act’s exchanges to lower health care costs for consumers and improve access to health care. Part 2 of the Notice of...more
Over the last year, we have seen volatility in the healthcare industry overall, and Medicare Advantage (“MA”) and Medicare Part D plans (together, “Plans”) have not been immune. Particularly because of their risk adjustment...more
On March 26, 2020, the Manhattan U.S. Attorney’s Office filed suit against Anthem, Inc. for violations of the False Claims Act. The complaint alleges that between 2014–2018, Anthem submitted inaccurate diagnosis codes to CMS...more
On December 31, 2019, a 3-0 panel of the United States Court of Appeals for the Tenth Circuit upheld the methodology adopted by HHS to administer the risk adjustment program under the Affordable Care Act (ACA). See New Mexico...more
On December 31, 2019, the Tenth Circuit Court of Appeals upheld the Department of Health & Human Services’ Affordable Care Act (ACA) risk adjustment methodology in New Mexico Health Connections v. HHS, No. 18-2186 (10th Cir....more
Delve into compliance hot topics and issues, including risk adjustment, CMS compliance, ethical leadership, data security, audits, and the challenges of the job. You’ll learn the latest practices, share strategies, and...more