Risk Adjustment & Attribution
Expert articles and analysis related to risk adjustment & attribution.
AI Summary — Last 30 Days
Risk adjustment enforcement is moving from retrospective plan audits into a broader provider-and-plan accountability regime: HHS OIG audits found HumanaChoice and UnitedHealthcare of Wisconsin submitted unsupported Medicare Advantage diagnoses tied to nearly $180 million in estimated overpayments, while DOJ’s $541.5 million settlement with The Villages Health signals escalating False Claims Act exposure for provider groups participating in MA coding operations. For VBC stakeholders, the near-term strategic shift is clear: attribution, documentation integrity, encounter-data governance, and vendor oversight are becoming core financial controls, not back-office compliance functions—especially as MedPAC’s MA overpayment estimates and stakeholder pushback keep pressure on CMS under Administrator Dr. Mehmet Oz to tighten risk adjustment while preserving legitimate coding for complex populations. See the HHS OIG audit coverage on Humana and UnitedHealthcare MA upcoding and the DOJ-related reporting on The Villages Health settlement.
Related Articles
Federal watchdog accuses Humana, UnitedHealthcare Medicare Advantage plans of upcoding
Newly released HHS OIG audits of HumanaChoice and UnitedHealthcare of Wisconsin found both plans frequently exaggerated the health needs of their members, generating almost $180 million in overpayment...
Four FCA Settlements Signal Intensifying DOJ Crackdown On Medicare Advantage Diagnosis Coding Programs - londoninsider.co.uk
Four FCA Settlements Signal Intensifying DOJ Crackdown On Medicare Advantage Diagnosis Coding Programs londoninsider.co.uk
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UnitedHealthcare of Wisconsin, Inc. (Contract H5253) Submitted to CMS - Office of Inspector General (.gov)
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UnitedHealthcare of Wisconsin, Inc. (Contract H5253) Submitted to CMS Office of Inspector General (.gov)
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That HumanaChoice (Contract H5216) Submitted to CMS - Office of Inspector General (.gov)
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That HumanaChoice (Contract H5216) Submitted to CMS Office of Inspector General (.gov)
A Vision for Modernizing Medicare Risk Adjustment: Building the Evidence for Reform
A Vision for Modernizing Medicare Risk Adjustment: Building the Evidence for Reform Margolis Institute for Health Policy
The Villages Health System $541.5 Million Settlement: A New Frontier in Medicare Advantage Risk Adjustment Enforcement - natlawreview.com
The Villages Health System $541.5 Million Settlement: A New Frontier in Medicare Advantage Risk Adjustment Enforcement natlawreview.com
Accuracy of Medicare Advantage risk adjustment at the plan level - medpac.gov
Accuracy of Medicare Advantage risk adjustment at the plan level medpac.gov
The Villages Health System Agrees to $541.5M Settlement
Bankrupt Villages Health ordered to pay $541 million for bilking Medicare Advantage
Bankrupt Villages Health ordered to pay $541 million for bilking Medicare Advantage Villages-News.com
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare
Humana-owned Villages Health agrees to $542M settlement for overbilling Medicare Healthcare Dive