Celebrating 20 Years!
As we celebrate our firm’s 20th anniversary, we want to take a moment to express our gratitude for your trust and collaboration.
Med Supp Mystery: The Case of the Missing MACRA Guaranteed Issue Language
Medicare Supplement (Med Supp, a/k/a Medigap) guaranteed issue rights have become a hot topic. Even late-night comedians are talking about the challenge faced by people in Medicare Advantage (MA) for more than a year who would like to return to Original Medicare and purchase a Med Supp policy.
Strategic Health Law turns 20!
Hear the story behind our founding and mission. Elizabeth [...]
New Administration’s Focus On Fraud Likely to Lead to Continued Scrutiny of Medicare Advantage Risk Adjustment
By Sandra Durkin Health plans wondering what type of [...]
The IRA’s Inadvertent Boost of Medicare Advantage
By Elizabeth Lippincott The Inflation Reduction Act Part D [...]
OIG Continues to Challenge MAO use of HRAs; CMS Continues to Reject Recommendations to Restrict Use
In a report issued in October 2024, the Office of Inspector General (“OIG”) within the Department of Health and Human Services (“HHS”) expressed concern that health risk assessments (“HRAs”) and chart reviews used by Medicare Advantage organizations (“MAOs”) are being misused to drive up payments from the government, rather than to improve member care.
New DOJ Whistleblower Program for Commercial Fraud Reports
On August 1, 2024, the U.S. Department of Justice (DOJ) introduced its Corporate Whistleblower Awards Pilot Program, a three-year program designed to fill gaps in federal agency whistleblower programs. A key function of this new program is to bolster enforcement of misconduct that is not prosecutable under the False Claims Act (FCA). The FCA only imposes liability for fraud against the federal government, which creates a gap in enforcement for fraud against other organizations or individuals. The Whistleblower Pilot Program targets misconduct against non-federal government organizations or individuals, such as private payors or patients.
CMS Updates ODAG/CDAG Guidance for MA and Part D Plans
On July 18, 2024, the Centers for Medicare & Medicaid Services (CMS) published an update to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (Updated Guidance). CMS had not updated guidance for organization determinations, appeals, and grievances (ODAG) in the Part C program and coverage determinations, appeals and grievances (CDAG) in the Part D program since 2019. The Updated Guidance reflects recent changes to the regulations governing ODAGs, clarifications on the role of representatives in the ODAG/CDAG process, and terminology changes to align with updated regulations.
The Regulatory Pendulum Is in Full Swing for Medicare Plans: Five Things You Can Count on in a Dynamic Regulatory Environment
The pendulum of the Medicare plan regulatory environment—which grew increasingly stringent under the Biden administration—probably reached its amplitude in the last few weeks and began to swing in the opposite direction. Having seen several oscillations of this political pendulum, I wanted to share some insights about what these changes mean for Medicare plans, as well as what lawyers and business teams can count on to stay constant.
BREAKING NEWS
A Texas District Court has stayed the implementation of the Medicare Advantage and Part D agent compensation provisions of the CY 2025 Final Rule for all affected parties.