Sandra Durkin

Health plans wondering what type of oversight to expect from the new administration can anticipate continued scrutiny of risk adjusted payments to Medicare Advantage organizations. While Trump has said that he will “love and cherish” Social Security and Medicare and does not plan on cuts to those programs, he more recently caveated that cuts could come if the administration finds abuse or waste.

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.

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.

In recent years, sustained oversight and enforcement by the federal government has made risk adjustment (RA) a top compliance priority for Medicare Advantage (MA) organizations. Complete and accurate coding of member conditions is critical for MA plan success. A plan that undercodes (fails to capture member conditions that impact treatment) will not have sufficient resources to manage the care of its members, while a plan that overcodes (submits unsupported diagnoses to the government) faces potentially devastating legal risk.

Guidance from the Office of Inspector General (OIG) and Centers for Medicare & Medicaid Services (CMS) imposes restrictions that go beyond the long-standing prohibition on Medicare Advantage (MA) organizations offering cash or cash equivalents as reward items or nominal gifts.

Last Friday the Centers for Medicare and Medicaid Services (CMS) released the 2020 Part C and Part D Program Audit and Enforcement Report. The purpose of program audits is to evaluate Medicare Advantage (MA) and Part D plan sponsors’ compliance with core program requirements, including ensuring that sponsors provide beneficiaries with access to medically necessary services and medications. The annual program audit and enforcement report provides background information on the program audit process, a summary of the 2020 program audits, as well as enforcement actions taken by CMS in the last year.

One theme that bubbled to the surface of cultural conversations around healthcare over the last year is the notion that “mental health is health.” Whether you’re a parent of children who struggled with isolation during a year of virtual school, a person who relied on in-person support for mental and behavioral health issues before the pandemic, or a healthcare professional trying to meet the needs of patients who are in increasing need of services for mental illness and substance use disorders, you know that COVID-19 has had an enormous, negative impact on mental health.

This week marks the anniversary of the World Health Organization declaring COVID-19 to be a pandemic, the United States entering a state of national emergency, and the Centers for Disease Control and Prevention (CDC) issuing the first set of restrictions in the United States. As we acknowledge these dates, and ruefully reflect on the emails from colleagues and signs hanging on the doors of our favorite restaurants saying, “Stay safe, we’ll see you in two weeks,” it is impossible not to reflect on how much our lives have changed in the last year, and to evaluate how many of those changes will be with us for the long term. We may disagree on when restaurants should reopen and kids should go back to school, but one thing on which patients, providers, plans, and lawmakers seem to agree is that telehealth is not going away.

At first glance, surprise billing seems like an issue that should have been straightforward to address. Patients, health plans, providers, and legislators of both parties supported legislation to protect consumers from unexpected medical bills from out-of-network providers. Nevertheless, lawmakers continued to debate the issue for years. In December, in the midst of a pandemic, during which some patients received substantial bills related to their COVID-19 care, Congress enacted federal legislation to rein in unexpected bills with the No Surprises Act, a ban on surprise billing tucked into the year-end spending bill passed on December 21, 2020. The prohibition goes into effect on January 1, 2022. Before that, we will see new rules from the Department of Health and Human Services (HHS) establishing processes for resolving out-of-network payment disputes between providers and those health plans subject to the new law.

We witnessed a peaceful transfer of presidential power in the United States last week. Following an inauguration in which President Biden pledged to take on a “raging virus” and “make health care secure for all,” the new administration dug in and got to work. Indeed, on the first day in office, President Biden issued seventeen executive orders, memoranda, and proclamations covering issues ranging from the environment to immigration to the economy.