Jason Christ on Medicare Advantage

CMS Doubles Down on Medicare Advantage Recoupment: Announces Aggressive RADV Strategy to Reclaim Billions

On May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) announced an aggressive plan (Plan) to expand its efforts to address fraud, waste, and abuse in Medicare Advantage (MA)....more

6/11/2025 / Appeals , Audits , Centers for Medicare & Medicaid Services (CMS) , Enforcement Actions , Government Agencies , Healthcare Fraud , Medicare , Medicare Advantage , OIG , Risk Management

A Closer Look at Proposed Changes to Medicare Advantage in the “No UPCODE Act”

On March 25, 2025, U.S. Senators Bill Cassidy, M.S. (R-LA) and Jeff Merkley (D-OR) introduced the No Unreasonable Payments, Coding, or Diagnoses for the Elderly (No UPCODE) Act (the “Bill”)....more

4/8/2025 / Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , Government Agencies , Healthcare , Healthcare Reform , Insurance Industry , Medicare , Medicare Advantage , New Legislation , Proposed Legislation , Risk Assessment

CMS Issuing First Risk Adjustment Data Validation Audit Notices for PY2018 Since the RADV Final Rule

The Centers for Medicare and Medicaid Services (CMS) is issuing, what will amount to be, very significant Risk Adjustment Data Validation (RADV) Audit notices for PY2018 to Medicare Advantage Organizations (MAOs)....more

11/15/2024 / Audits , Centers for Medicare & Medicaid Services (CMS) , Medicare , Medicare Advantage , Medicare Advantage Organizations (MAOs)

Rare DOJ Criminal Indictment Related to Medicare Advantage Risk Adjustment

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

11/2/2023 / Criminal Prosecution , Department of Justice (DOJ) , Enforcement Actions , Fee-for-Service , Health Insurance , Healthcare , Healthcare Fraud , Indictments , Medicare Advantage , Medicare Part C , Risk Adjustment Formula

CMS’s Final Rule on Medicare Advantage Risk Adjustment Data Validation

On February 1, 2023, the Centers for Medicare & Medicaid Services (CMS) published a final rule outlining its audit methodology and related policies for its Medicare Advantage (MA) Risk Adjustment Data Validation (RADV)...more

2/3/2023 / Centers for Medicare & Medicaid Services (CMS) , Final Rules , Medicare , Medicare Advantage , Medicare Advantage Organizations (MAOs)

The Department of Justice (“DOJ”) Continues its Medicare Advantage (“MA”) Enforcement Efforts with a $90 Million Dollar Settlement...

On August 30, 2021, the DOJ announced a $90 million dollar settlement with Sutter Health and affiliates (“Sutter Health”) to settle False Claims Act (“FCA”) allegations brought by qui tam relator, Kathy Ormsby, related to the...more

9/2/2021 / Centers for Medicare & Medicaid Services (CMS) , Department of Justice (DOJ) , False Claims Act (FCA) , Medicare Advantage , OIG

OIG Audits on Medicare Advantage Plans Continue

On April 19, 2021, the Office of Inspector General’s (OIG) Office of Audit Services (OAS) released the results of an audit conducted on the accuracy of diagnosis codes submitted to CMS by Humana, Inc. for 2015 dates of...more

4/27/2021 / Audits , Centers for Medicare & Medicaid Services (CMS) , Medicare , Medicare Advantage , OIG

HHS-OIG Work Plan – Medicare Advantage

Providers, plans, and vendors that provide services under the Medicare Advantage program, should be aware that the Office of Inspector General (“OIG”) of the U.S. Department of Health and Human Services (“HHS”) is once again...more

9/25/2018 / Centers for Medicare & Medicaid Services (CMS) , Department of Health and Human Services (HHS) , False Claims Act (FCA) , Hospitals , Managed Care Contracts , Medicare , Medicare Advantage , Medicare Part A , Medicare Part B , OIG , Physicians , Work Plans

Jason Christ

Epstein Becker & Green

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