---
type: source
title: "Risk Adjustment Continues to Be a Major Focus in Medicare Advantage (DOJ/OIG Enforcement)"
author: "Morgan Lewis"
url: https://www.morganlewis.com/pubs/2025/04/risk-adjustment-continues-to-be-a-major-focus-in-medicare-advantage
date: 2025-04-01
domain: health
secondary_domains: []
format: report
status: unprocessed
priority: medium
tags: [risk-adjustment, false-claims-act, doj, oig, enforcement, upcoding, medicare-advantage]
---

## Content

### DOJ Enforcement Landscape

- Significant DOJ settlements in March-April 2025 based on alleged false diagnosis codes
- Government position: submitting unsupported diagnostic codes to reap higher capitated rates = False Claims Act violation
- Of 44 managed care audits by HHS OIG since 2017, 42 focused on diagnosis coding
- Audits found 70% of diagnosis codes not supported by medical records

### Legislative Action

- No UPCODE Act reintroduced March 2025 (originally introduced 2023)
- Bipartisan support for upcoding enforcement
- New CMS administrator (confirmed April 3, 2025) prioritizes upcoding enforcement

### Industry Impact

- Nearly every major MA plan has faced or is facing federal fraud allegations
- UnitedHealth, Humana, Elevance, Kaiser all involved in enforcement actions
- The enforcement focus creates regulatory risk for the entire MA industry

## Agent Notes
**Why this matters:** The enforcement trajectory shows bipartisan political will to address MA upcoding — rare in US healthcare politics. This compounds with V28 and chart review exclusion to create a multi-front reform pressure on MA economics.
**What surprised me:** The bipartisan framing. Healthcare policy is typically partisan, but MA overpayment reform has support from both sides (fiscal conservatives + progressive reformers).
**KB connections:** [[CMS 2027 chart review exclusion targets vertical integration profit arbitrage by removing upcoded diagnoses from MA risk scoring]]
**Extraction hints:** The bipartisan convergence on MA reform is itself a claim-worthy insight — it suggests the political economy has shifted enough that reform is likely.

## Curator Notes
PRIMARY CONNECTION: [[CMS 2027 chart review exclusion targets vertical integration profit arbitrage by removing upcoded diagnoses from MA risk scoring]]
WHY ARCHIVED: Enforcement context complements the policy/regulatory sources — shows both regulatory and legal paths converging on risk adjustment reform.
EXTRACTION HINT: Focus on the bipartisan enforcement convergence, not individual cases.
