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
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
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
On November 15, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule titled Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit...more
12/13/2023
/ Centers for Medicare & Medicaid Services (CMS) ,
Comment Period ,
Drug Pricing ,
Health Insurance ,
Health Plan Sponsors ,
Medicare ,
Medicare Advantage ,
Medicare Part D ,
Out-of-Pocket Expenses ,
Pharmaceutical Industry ,
Prescription Drugs ,
Proposed Rules
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
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
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
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