Wave of federal risk adjustment investigations reveals pain points for providers

Why This Topic Matters

The article is relevant because risk adjustment enforcement can affect Medicare Advantage organizations and may create liability or contract issues for providers working with them. It helps compliance, legal, and coding stakeholders understand the broader regulatory environment surrounding Medicare Advantage payment integrity.

Article Sections

1. Risk adjustment scrutiny increases

   Introduces the growing attention from federal investigators and auditors toward Medicare Advantage risk adjustment practices. It frames the article’s focus on enforcement trends and compliance concerns.

2. Kaiser Foundation Health Plan settlement

   Summarizes a DOJ settlement involving Medicare Advantage-related diagnosis reporting allegations and discusses the role of internal review and outside consulting in the matter.

3. Other investigations crop up

   Reviews additional federal actions and oversight developments involving other organizations. It includes whistleblower matters, DOJ litigation, and OIG findings related to Medicare Advantage payment practices.

4. Possible provider blowback

   Explores how increased scrutiny of Medicare Advantage plans may extend to contracted provider organizations. It discusses potential liability, chart review concerns, and contract implications.

5. How a Biden admin may refocus

   Considers how enforcement priorities may shift under a new administration. It addresses the possibility of renewed focus on individuals, claim chains, and prosecutorial strategy.