Risk Adjustment & Coding
Expert articles and analysis related to risk adjustment & coding.
AI Summary — Last 30 Days
CMS and HHS oversight of Medicare Advantage risk adjustment is tightening, with new OIG audits alleging unsupported diagnosis codes at UnitedHealthcare and Humana MA contracts and estimating large overpayments tied to coding intensity—reinforcing that VBC revenue strategies dependent on retrospective chart reviews, in-home assessments, and aggressive HCC capture face rising audit and repayment risk. DOJ’s $22.5M False Claims Act settlement with Independence Blue Cross over MA diagnosis coding further signals that risk adjustment compliance is becoming a core enforcement front, not just a technical CMS reconciliation issue, as payers and delegated provider groups absorb more downside exposure in MA and value-based contracts. For ACOs, health systems, and payer partners, the strategic shift is toward prospective, encounter-based documentation integrity and defensible population risk stratification, as MedPAC’s high MA overpayment estimates and Trump administration CMS scrutiny increase pressure to separate legitimate complexity coding from revenue-maximizing upcoding (OIG MA compliance audits; DOJ Independence Blue Cross settlement).
Related Articles
Office of Public Affairs | Independence Blue Cross to Pay $22.5M to Resolve False Claims Act Allegations - Department of Justice (.gov)
Office of Public Affairs | Independence Blue Cross to Pay $22.5M to Resolve False Claims Act Allegations Department of Justice (.gov)
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UnitedHealthcare Benefits of Texas, Inc. (Contract H0609), Submitted to CMS - Office of Inspector General (.gov)
Medicare Advantage Compliance Audit of Specific Diagnosis Codes That UnitedHealthcare Benefits of Texas, Inc. (Contract H0609), Submitted to CMS Office of Inspector General (.gov)
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)
ACA RADV Is More Than a Compliance Requirement
How ACA Risk Adjustment Data Validation can affect financial results, operational strategy, and long-term risk adjustment performance ACA Risk Adjustment Data Validation (RADV) is not simply a regulat...
Duke-Margolis Has Vision for Modernizing MA Risk Adjustment
Duke-Margolis Has Vision for Modernizing MA Risk Adjustment HCI Innovation Group
Independence Blue Cross to pay $22.5M to resolve MA fraud allegations
Independence Blue Cross will pay to resolve allegations it defrauded Medicare by inflating diagnosis codes for MA beneficiaries. The payer said its settlement and others reflect “industry-wide challen...
Independence Blue Cross to Pay $22.5 Million in Medicare Case
Independence Blue Cross to Pay $22.5 Million in Medicare Case MyChesCo