Risk Adjustment & Coding
Expert articles and analysis related to risk adjustment & coding.
AI Summary — Last 7 Days
DOJ enforcement against Medicare Advantage risk adjustment intensified this week, with Humana-owned The Villages Health agreeing to a roughly $542 million settlement over alleged unsupported diagnosis codes for MA members from 2020–2024—an unmistakable warning that provider-led coding infrastructure, not just payer submissions, is in the False Claims Act spotlight (Healthcare Dive). For VBC organizations, the emerging tension is sharper: accurate risk capture remains financially critical for MA, ACO, and delegated-risk models, but unsupported HCC coding, weak chart validation, and aggressive vendor/provider workflows now carry escalating repayment, enforcement, and reputational risk. Legal and policy commentary also points to broader DOJ scrutiny of MA upcoding, reinforcing the need for ACOs, physician groups, and payers to harden compliance controls around documentation, retrospective reviews, and coding governance before entering or expanding value-based contracts (WilmerHale).
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The Central Florida provider manufactured fake diagnosis codes for its Medicare Advantage patients from 2020 to 2024, the DOJ said. Humana bought The Villages Health last year.
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Week in Washington 08/27/26
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AMGA Statement on CY 2027 Medicare Advantage Rate Notice - amga.org
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