On September 14, 2020, the Centers for Medicare & Medicaid Services (“CMS”) issued the Advance Notice of Methodological Changes for Calendar Year (CY) 2022 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies – Part I, CMS-HCC Risk Adjustment Model (the “Advance Notice”).  CMS is issuing the Advance Notice in two parts: Part I includes key information about the Medicare Advantage CMS-Hierarchical Condition Categories (“HCC”) risk adjustment model and the use of encounter data for CY2022.  Part II, which will include other changes to the CY2022 payment methodologies, will be issued later this Fall.   CMS will announce the CY2022 MA capitation rates and final payment policies no later than Monday, April 5, 2021.
Continue Reading CMS Issues the 2022 Medicare Advantage Advance Notice Part I – Risk Adjustment

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”) case of United States of America ex rel. Swoben v. Scan Health Plan, et al. (CV 09-5013-JFW (JEMx)) (the “Swoben Case”) (brought by qui tam relator James M. Swoben and joined by the Department of Justice (“DOJ”)). [1]

Although the ruling was undoubtedly well received by UnitedHealthcare (“UHC”), its parent company, UnitedHealth Group Inc. (“UHG”), and the other Swoben Case defendants, the defendants’ happiness with the dismissal may have been tempered because the ruling gives the DOJ an opportunity to amend and refile its complaint with the Court. Given the DOJ’s recent history of aggressively pursuing cases of potential fraud in the MA space, it is very likely that the DOJ will amend and refile its complaint in the near future.
Continue Reading Alert: In a Surprise Decision Issued on October 5, 2017, Honorable John Walter, United States District Judge, Dismissed a Medicare Advantage Risk Adjustment Fraud Suit Against UnitedHealthcare