Two recent announcements from the Centers for Medicare & Medicaid Services (CMS) offer early indicators as to how the Trump administration, including CMS administrator Dr. Mehmet Oz, may approach the Medicare Advantage (MA)...more
The Department of Justice announced this week that California-based primary care provider Seoul Medical Group, Inc. (SMG), SMG’s former president and majority owner, and California-based radiology group Renaissance Imaging...more
3/31/2025
/ Centers for Medicare & Medicaid Services (CMS) ,
Department of Health and Human Services (HHS) ,
Department of Justice (DOJ) ,
False Claims Act (FCA) ,
Health Care Providers ,
Healthcare Fraud ,
Medicare Advantage ,
Medicare Fraud ,
OIG ,
Physicians ,
Settlement
On April 4, the Centers for Medicare & Medicaid Services (CMS) issued the Contract Year (CY) 2025 Medicare Advantage (MA) Final Rule (Final Rule), which will have significant implications for MA plans and other industry...more
4/16/2024
/ Agents ,
Anti-Competitive ,
Beneficiaries ,
Brokers ,
Centers for Medicare & Medicaid Services (CMS) ,
Equity ,
Final Rules ,
Healthcare ,
Marketing ,
MCOs ,
Medicaid ,
Medicare Advantage ,
Medicare Part D ,
Mental Health ,
Shareholders ,
Third-Party Service Provider
Last week, the U.S. Department of Justice (DOJ) announced a $22.4 million settlement resolving allegations that Martin’s Point Health Care, Inc. (Martin’s Point) violated the False Claims Act (FCA) by submitting inaccurate...more
On February 1, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) Program Final Rule (Final Rule), which will take effect on April 3, 2023. The...more
On December 14, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that contemplates several changes to, and clarifications of, guidance for the Medicare Advantage (MA) program in coverage year 2024....more
12/21/2022
/ Centers for Medicare & Medicaid Services (CMS) ,
Comment Period ,
Department of Health and Human Services (HHS) ,
Equity ,
Health Care Providers ,
Marketing ,
Medicare ,
Medicare Advantage ,
Medicare Part A ,
Medicare Part B ,
Medicare Part C ,
Medicare Part D ,
Notice Requirements ,
Overpayment ,
Proposed Rules ,
Star Ratings ,
Termination Clauses ,
Translations ,
Utilization Review
On November 14, Judge Edward Chen in the Northern District of California issued rulings on the pending motions to dismiss in U.S. ex rel. Osinek v. Kaiser Permanente, granting in part and denying in part Kaiser’s motion to...more
In a decision issued on September 30, Judge Andrew Carter of the U.S. District Court for the Southern District of New York denied Anthem Inc.’s motion to dismiss a government lawsuit filed in March 2020 claiming Anthem...more
10/7/2022
/ Anthem Insurance ,
Dismissals ,
Failure to Comply ,
False Claims Act (FCA) ,
Insurance Litigation ,
Kaiser Permanente ,
Medical Billing Codes ,
Medicare Advantage ,
Medicare Part C ,
New York ,
Overpayment
In a September 2022 filing in U.S. ex rel. Osinek v. Kaiser Permanente, the Kaiser Permanente consortium defendants (Kaiser) highlighted the distinction between clinically inaccurate diagnoses (factual falsity) and clinically...more
10/7/2022
/ Clinical Evaluations ,
Enforcement ,
False Claims Act (FCA) ,
Health Care Providers ,
Kaiser Permanente ,
Managed Service Providers (MSPs) ,
Medical Billing Codes ,
Medicare Advantage ,
Objective Falsity ,
Physicians ,
Qui Tam ,
Regulatory Oversight