Aetna Settles MA Risk Adjustment Case
Aetna will pay $117.7 million to resolve False Claims Act allegations that it overbilled the Medicare program. The agreement settles claims related to past risk adjustment submissions in Medicare Advantage (MA). The Department of Justice said some diagnostic codes were not fully supported but were still submitted to secure higher payouts. Aetna also failed to withdraw some inaccurate diagnoses.
Additional articles: https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-upcoding-claims/ and https://www.beckerspayer.com/payer/medicare-advantage/aetna-to-pay-118m-to-resolve-medicare-advantage-upcoding-allegations/
(Some articles may require a subscription.)
#medicareadvantage #riskadjustment #overpayments #fwa
CMS Goes Hollywood On Fraud
The Centers for Medicare and Medicaid Services (CMS) has gone Hollywood with glitzy ads bringing attention to fraud, waste, and abuse (FWA). The Trump administration has had some success. The Department of Justice reported a record $6.8 billion in settlements and judgments under the False Claims Act in the fiscal year that ended Sept. 30, 2025.
#fwa #cms
https://www.medpagetoday.com/special-reports/exclusives/120256
Researchers Track MA Diversity
A study in the American Journal of Managed Care finds that the demographics and clinical statuses of Medicare Advantage (MA) enrollees have been getting more diverse over time. The share of dually eligible beneficiaries increased from 13% to 23%, and the share of low-income subsidy recipients went up from 19.4% to 27%. Special Needs Plan (SNP) enrollment has surged. Black beneficiaries rose from 12.7% to 18.3%.
More evidence that congressional policy arm MedPAC’s analysis of favorable selection in MA is bogus.
#medicareadvantage
KFF Reviews Medicare Drug Negotiations
A new briefer from healthcare policy group KFF looks at progress in year 1 and 2 of Medicare drug price negotiations as year 3 kicks off.
#drugpricing #branddrugmakers #medicare #partd
https://www.kff.org/medicare/key-facts-about-medicare-drug-price-negotiation/
— Marc S. Ryan
