The Centers for Medicare & Medicaid Services (CMS) is signaling a significant shift in the Medicare Advantage (MA) payment environment with a particular focus on risk adjustment. CMS has announced plans to rerun MA risk scores for Payment Years 2020–2022 to recover overpayments tied to unsupported diagnoses.
At the same time, CMS is launching targeted reviews of diagnoses reported through in-home health risk assessments (IHRAs) for 2023, following government findings that billions of dollars in MA payments were supported solely by health risk assessments rather than encounter-based care.
Compounding this scrutiny, proposed changes in the recent Advanced Notice could further reshape the risk adjustment payment landscape by excluding diagnoses derived solely from unlinked chart review records.
Taken together, these developments reflect a coordinated and escalating posture by the federal government. The exposure and financial impact is no longer theoretical. Healthcare organizations participating in the MA ecosystem must reassess their risk-adjustment operations, financial forecasting, and compliance controls. These regulatory actions also intersect with an increasingly active enforcement environment, including heightened scrutiny by the U.S. Department of Justice and related federal oversight agencies focused on MA coding and payment integrity. Join healthcare attorneys and health plan advisors for a discussion of CMS’s evolving risk-adjustment framework and what it means for MA plans navigating the program’s increasingly complex regulatory landscape.
This program is designed for leaders responsible for Medicare Advantage strategy, operations, and compliance, including:
- Medicare Advantage health plan executives, strategy and operations leaders
- Healthcare provider organizations participating in MA contracts or value-based arrangements
- Compliance officers, regulatory counsel, and risk-adjustment legal teams
- Finance leaders, actuaries, and reimbursement strategists
- Risk-adjustment leaders
- Private equity investors and healthcare advisors evaluating MA-exposed assets
Speakers:
- Christine Clements, Regulatory Lead, Healthcare Industry Team, Sheppard
- Danielle Vrabie, Litigation Lead, Healthcare Industry Team, Sheppard
- Matt Krizmanich, Senior Partner, HealthScape
- Alexis Levy, Senior Partner, HealthScape