False Claims Act Enforcement Involving Medicare Advantage Plans: Recent Cases and Current Trends

• May 18, 2023

• G. Norman Acker III , K&L Gates LLP
• John H. Lawrence , K&L Gates LLP
• Stephen Bittinger , K&L Gates LLP
• Melissa Yates , K&L Gates LLP

With Medicare Advantage (MA or Medicare Part C) on pace to exceed traditional Medicare by 2030, the level of scrutiny and False Claims Act (FCA) litigation relating to these plans has increased dramatically. Private MA organizations (MAOs) that offer insurance plans and administer Medicare benefits for the Centers for Medicare & Medicaid Services (CMS) under Medicare Part C have become an increasing target for FCA allegations. The capitated payment structure in Medicare Part C was intended to appropriately compensate MAOs for carrying beneficiaries with higher risk of serious health conditions. However, this risk adjustment process has proven to be susceptible to inappropriate manipulation for increased reimbursement.

ARTICLE TAGS

• Payers, Plans, and Managed Care Practice Group
• Fraud and Compliance
• Government Reimbursement
• Health Insurance