Risk Adjustment & Compliance
Expert articles and analysis related to risk adjustment & compliance.
AI Summary — Last 7 Days
Medicare Advantage risk adjustment and utilization-management scrutiny intensified this week, with DOJ pressing Elevance for access to a senior executive in an MA fraud case and Aetna agreeing to a $117.7M false-claims settlement tied to MA diagnosis submissions—signals that RAF/HCC coding, chart review, and vendor-enabled documentation programs remain high-enforcement-risk areas for plans and delegated risk providers (STAT on Elevance/DOJ). At the same time, bipartisan House activity targeting MA prior authorization and denial practices, along with KFF’s review of CMS MA rule changes, points to a widening policy tension: the Trump administration’s CMS is balancing consumer-protection oversight with plan flexibility, while ACOs, MA risk groups, and health systems face tighter compliance expectations around coding integrity, medical necessity, and post-acute access (MedCity on bipartisan MA oversight bill
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