News & Analysis as of

Risk Adjustment Formula

Foley & Lardner LLP

OIG Issues Report Suggesting Medicare Advantage Companies Perform Chart Reviews and Health Risk Assessments to Drive Higher...

Foley & Lardner LLP on

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

Sheppard Mullin Richter & Hampton LLP

Sutter Health Settles Medicare Fraud Case For $90 Million: The Largest Settlement For Medicare Advantage Fraud

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

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

Sheppard Mullin Richter & Hampton LLP

Biden Administration Finalizes Lower Out-of-Pocket Costs for Exchange Plans, Targets Health Equity and Access

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

Sheppard Mullin Richter & Hampton LLP

CMS to the Rescue for MA and Part D Plans – Rate Announcement Includes Significant Increase in Plan Payments for 2022

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

King & Spalding

Government Files False Claims Act Suit Against Anthem for Allegedly Submitting Inaccurate Diagnosis Codes Used in Risk Adjustment...

King & Spalding on

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

Manatt, Phelps & Phillips, LLP

[Webinar] COVID-19: The Road Ahead for Commercial Health Insurance - April 23rd, 2:00 pm - 3:00 pm ET

Examine the Evolving Challenges That Lie Ahead for Healthcare Stakeholders and State Regulators—and What You Can Do Now to Prepare and Protect Your Organization—at a New Manatt Webinar. Effective health insurance...more

King & Spalding

Tenth Circuit Upholds HHS Risk Adjustment Methodology

King & Spalding on

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

Mintz - Health Care Viewpoints

Did the Tenth Circuit Just Put the Final Nail in the Coffin for Challenges to the Use of “Statewide Average Premium” in Risk...

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

Health Care Compliance Association (HCCA)

[Event] Managed Care Compliance Conference - January 26th - 29th, Lake Buena Vista, FL

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

Carlton Fields

Court of Federal Claims Finds HHS Offset Invalid Under Colorado’s Insurance Liquidating Priority Scheme

Carlton Fields on

The U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (HHS) operates the reinsurance and risk-adjustments program for Colorado, including the application of the “netting rule” — a method...more

Bass, Berry & Sims PLC

Medicare Advantage: Recent Developments in FCA Enforcement

The Medicare Advantage program, which allows private insurance companies to offer and administer Medicare benefits, continues to be an area of sharp scrutiny for False Claims Act (FCA) enforcement despite some significant...more

McDermott Will & Emery

CMS Seeks to Provide Flexibility and Facilitate Innovation in Medicare Advantage and Part D

The Centers for Medicare and Medicaid Services (CMS) recently released several significant Medicare Advantage (MA) and Part D guidance documents outlining new Center for Medicare and Medicaid Innovation (CMMI) programs and...more

Mintz - Health Care Viewpoints

CMS Proposes Changes to Medicare Advantage Program for CY 2020

CMS recently proposed several important changes for the Medicare Advantage ("MA") program that relate to payment, benefit design, and new actions to combat the opioid crisis. These changes, among others, were proposed in...more

Bass, Berry & Sims PLC

DOJ Intervenes in Another Medicare Advantage Risk Adjustment FCA Suit

Bass, Berry & Sims PLC on

On December 11, 2018, the United States announced that it has elected to intervene in a False Claims Act (FCA) lawsuit filed against Sutter Health and its affiliated entity Palo Alto Medical Foundation (PAMF) alleging that...more

Troutman Pepper

CMS Proposed Rule Could Dramatically Increase Recoupments From Medicare Advantage Insurers

Troutman Pepper on

On October 26, the Centers for Medicare and Medicaid Services (CMS) issued a notice of proposed rulemaking that would significantly alter the risk adjustment data validation (RADV) methodology that applies to Medicare...more

Mintz - Health Care Viewpoints

New Mexico Court Affirms Ruling in ACA Risk Corridor Case

On October 19, 2018, a New Mexico district judge rejected a request from HHS to reconsider a February decision that had briefly led to the suspension of the ACA’s risk adjustment program. In February, District Judge James...more

Sheppard Mullin Richter & Hampton LLP

Blog Series: CMS Proposed Rule on Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit,...

On October 26, 2018, the Centers for Medicare and Medicaid Services (“CMS”) released for viewing a proposed rule that includes significant changes for Medicare Advantage organizations (“MAOs”), Part D prescription drug plan...more

Mintz - Health Care Viewpoints

Court Rules that Federal Government Must Make Cost Sharing Reduction Payments to Insurers

ACA plans scored a major victory last week when a federal court held that health plans participating on the ACA exchanges are entitled to unpaid cost sharing reduction (CSR) payments from the federal government. The case –...more

Farrell Fritz, P.C.

State Reallocation of FRAP Funds Not Barred By the ACA

Farrell Fritz, P.C. on

As the battle over the future of the Affordable Care Act (the “ACA”) continues, New York State scored a big victory earlier this month with the federal court decision of UnitedHealthcare of New York, Inc., et al. v. Vullo....more

Mintz - Health Care Viewpoints

CMS, In a Reversal, Announces Plans to Continue Funding Risk Adjustment Payments

On Wednesday, August 8, CMS filed a proposed rule clearing the way for the federal government to continue making payments under the ACA’s risk adjustment program for the benefit year 2018. The 2018 proposed rule is...more

Sheppard Mullin Richter & Hampton LLP

No Longer in Suspense: CMS Issues Final Rule Announcing that Risk Adjustment Program Transfers for 2017 will be Distributed in...

The Final Rule. In a Final Rule posted by CMS last Tuesday, July 24, 2018, CMS announced that $10.4 billion in “risk adjustment transfers” (“Risk Transfers”) for benefit year 2017 (as calculated pursuant to the Affordable...more

Baker Ober Health Law

CMS Reinstates ACA Risk Adjustment Payments

Baker Ober Health Law on

On Tuesday, July 24, the Centers for Medicare and Medicaid Services (CMS) issued a final rule intended to clarify the program methodology and reinstate payments under the Affordable Care Act's (ACA) permanent risk adjustment...more

King & Spalding

Insurers Not Entitled to Full ACA Risk Corridors Payments Says the United States Court of Appeals for the Federal Circuit

King & Spalding on

Resolving a split in the lower courts, the Federal Circuit issued two decisions on June 14, 2018, wherein the Court held that health insurers Moda Health Plan Inc. (Moda Health) and Land of Lincoln Mutual Health (Land of...more

Holland & Knight LLP

Federal Court Allows False Claims Act Case to Continue Against Medicare Advantage Insurer

Holland & Knight LLP on

In February of 2018, a United States District Court in the Central District of California dismissed only half of the claims in a qui tam case against United Health Group, Inc. (UHG), a Medicare Advantage plan provider. United...more

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