WHO IS AT RISK -

The federal government has indicated that it is still investigating, and could ultimately join a false claims whistleblower qui tam action against Aetna, Inc., Humana, Inc., Cigna, Inc. (through its Bravo Health unit) and Health Net, Inc. (now part of Centene). If other Medicare Advantage health plans are undertaking the type of risk adjustment program activities noted in the action, they also may be at risk of being the subject of federal government enforcement or other whistleblower claims. Indeed, it is clear that the risk adjustment approach of some Medicare Advantage Plans has caught the attention of both the federal government and the qui tam bar. We can only expect more lawsuits and enforcement initiatives to come. As a result, Medicare Advantage plans need to proactively and immediately conduct a comprehensive review of their overall approach to the HCC-RAF risk adjustment process. Suggested actions and background are below.

WHAT ACTIONS ARE NEEDED TO REDUCE LIABILITY EXPOSURE -

..Review and Improve Operations. Given recent enforcement action, Medicare Advantage health plans should consider an end to end review of their risk adjustment program activities that includes a careful examination of auditing protocols, relationships with providers and vendors, risk adjustment compliance programs and oversight, and risk adjustment incentive compensation structures for employees, vendors and providers. Use independent outside counsel experienced in Medicare Advantage risk adjustment to provide a showing of “good faith” intentions, to attempt to limit damage theories, and to avoid attorney-client privilege waiver issues...