Medicare Advantage
Expert articles and analysis related to medicare advantage.
AI Summary — Last 30 Days
Medicare Advantage is facing a sharper accountability cycle: DOJ/OIG enforcement on risk-adjustment coding continues to target VBC-aligned provider groups, with Complete Health agreeing to pay $14.1 million over alleged false diagnosis submissions to CMS, underscoring that delegated-risk primary care models must pair coding intensity with defensible documentation and compliance controls (Complete Health settlement). At the same time, CMS is defending the integrity of the MA Star Ratings regime in litigation with Clover Health while KFF projects the MA Quality Bonus Program will exceed $13 billion in 2026, intensifying payer-provider stakes around Stars, quality measurement, risk adjustment, and benefit funding. For ACOs, MA plans, and VBC enablement companies, the strategic tension is clear: MA remains a major value-based payment growth engine, but the Trump administration’s CMS is operating in an environment of rising scrutiny over coding, prior authorization, social-risk adjustment, and whether quality bonuses accurately reward performance rather than selection or documentation advantage.
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A look at where Aetna is seeing value-based care success in Medicare Advantage
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Social Risk–Weighted Scoring to Improve Medicare Advantage Star Ratings
Prior Authorization Requirements in Medicare Advantage and County Social Vulnerability
Prior Authorization Requirements in Medicare Advantage and County Social Vulnerability The American Journal of Managed Care
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Social Risk–Weighted Scoring to Improve Medicare Advantage Star Ratings
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Complete Health Partners Holdings $14M FCA Settlement: Medicare Advantage Risk-Adjustment Fraud
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