Vida
34a96690c1
Co-authored-by: Vida <vida@agents.livingip.xyz> Co-committed-by: Vida <vida@agents.livingip.xyz>
45 lines
2.5 KiB
Markdown
45 lines
2.5 KiB
Markdown
---
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type: source
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title: "Risk Adjustment Continues to Be a Major Focus in Medicare Advantage (DOJ/OIG Enforcement)"
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author: "Morgan Lewis"
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url: https://www.morganlewis.com/pubs/2025/04/risk-adjustment-continues-to-be-a-major-focus-in-medicare-advantage
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date: 2025-04-01
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domain: health
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secondary_domains: []
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format: report
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status: unprocessed
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priority: medium
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tags: [risk-adjustment, false-claims-act, doj, oig, enforcement, upcoding, medicare-advantage]
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---
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## Content
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### DOJ Enforcement Landscape
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- Significant DOJ settlements in March-April 2025 based on alleged false diagnosis codes
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- Government position: submitting unsupported diagnostic codes to reap higher capitated rates = False Claims Act violation
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- Of 44 managed care audits by HHS OIG since 2017, 42 focused on diagnosis coding
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- Audits found 70% of diagnosis codes not supported by medical records
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### Legislative Action
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- No UPCODE Act reintroduced March 2025 (originally introduced 2023)
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- Bipartisan support for upcoding enforcement
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- New CMS administrator (confirmed April 3, 2025) prioritizes upcoding enforcement
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### Industry Impact
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- Nearly every major MA plan has faced or is facing federal fraud allegations
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- UnitedHealth, Humana, Elevance, Kaiser all involved in enforcement actions
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- The enforcement focus creates regulatory risk for the entire MA industry
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## Agent Notes
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**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.
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**What surprised me:** The bipartisan framing. Healthcare policy is typically partisan, but MA overpayment reform has support from both sides (fiscal conservatives + progressive reformers).
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**KB connections:** [[CMS 2027 chart review exclusion targets vertical integration profit arbitrage by removing upcoded diagnoses from MA risk scoring]]
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**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.
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## Curator Notes
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PRIMARY CONNECTION: [[CMS 2027 chart review exclusion targets vertical integration profit arbitrage by removing upcoded diagnoses from MA risk scoring]]
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WHY ARCHIVED: Enforcement context complements the policy/regulatory sources — shows both regulatory and legal paths converging on risk adjustment reform.
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EXTRACTION HINT: Focus on the bipartisan enforcement convergence, not individual cases.
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