November 4, 2025 • 50 mins
Kathy Roe, Managing Attorney, Health Law Consultancy, speaks with Annie Shieh and Judith Waltz, Partner, Foley & Lardner, about the impact of recent changes to Medicare Advantage (MA) compliance on plans and providers. They discuss what plans and providers are responsible for when it comes to MA compliance, the current MA landscape, MA compliance changes from a plans perspective (including the current Administration and the 2026 Final Rule), MA compliance changes from a provider perspective (including the 60-day refund rule and recent litigation), and administrative enforcement actions. Annie and Judith spoke about this topic at AHLA’s 2025 Annual Meeting in San Diego, CA. From AHLA’s Payers, Plans, and Managed Care Practice Group.
Watch this episode: https://www.youtube.com/watch?v=vjRzb0UiNuY
Learn more about the AHLA 2025 Annual Meeting that took place in San Diego, CA: https://www.americanhealthlaw.org/annualmeeting
Learn more about AHLA’s 2025 Annual Meeting eProgram: https://educate.americanhealthlaw.org/local/catalog/view/product.php?productid=1472
Learn more about AHLA’s Payers, Plans, and Managed Care Practice Group: https://www.americanhealthlaw.org/practice-groups/practice-groups/payers-plans-and-managed-care
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_00 (00:04):
This episode of AHLA Speaking of Health Law is
brought to you by AHLA membersand donors like you.
For more information, visitAmerican Health Law.org.
SPEAKER_02 (00:17):
Hello, AHLA members.
Welcome to today's podcast.
I'm Kathy Rowe.
I am an attorney with Health LawConsultancy in Chicago, and I am
the chair of the Payers Plansand Managed Care Practice Group.
Today I'm bringing you twospeakers who presented on a
(00:40):
managed care topic at thissummer's AHLA annual meeting.
Annie, Judy, you want tointroduce yourself?
Hi everyone.
SPEAKER_01 (00:51):
My name's Annie Shea, and I have 16 years of
experience in Medicare AdvantageCompliance.
I am also on this year's AHLAAnnual Meeting Planning
Committee.
So very excited to look forwardto what new topics and speakers
will be coming our way.
And I'm also former chair of thePayers Plans Managed Care
Practice Group, same as Kathy.
Judy, you want to take it away?
SPEAKER_03 (01:13):
Sure.
So my name is Judy Waltz.
I'm a partner with Foley andLardner in the San Francisco
office.
I chair our health carepractice, which is about 60
dedicated healthcare lawyers.
The first part of my career Ispent with the federal
government in an office that hasnow been decommissioned, so to
speak, with in the San FranciscoRegional Office of the General
(01:37):
Counsel.
I had the pleasure of speakingwith Annie this summer at AHLA
and would encourage everyone toattend the annual meeting.
It's a very fun, not just uheducational event.
And I am a former chair of theHLA regulatory accreditation and
payment practice group, which isum one that I would highly
(02:01):
recommend, as well as the PPMC.
So, Annie, are you ready to jumpin?
SPEAKER_01 (02:08):
Yeah, let's get started.
So, what we'd like to covertoday is really how Medicare
vanish compliance impacts plansand providers.
So, where we'd like to start iswhose responsibility is it,
anyways?
And the short answer to thatquestion is it's both of our
responsibilities.
And I'm kind of speaking fromthe plan perspective because
that's where my career started.
(02:30):
So, health plans have fourprimary areas in responsibility
for vetting providers.
First is monthly screening.
So that requires checkingagainst the OIG exclusion list
as well as the GSA and the CMSpreclusion list if you're
involved in Medicare.
So that's the first requirement.
(02:50):
And one of the tricky areas isif you do delegate claims
processing to an entity, youalso need to make sure that they
are checking that monthlyexclusion list.
CMS will actually vet thisthrough their financial audits.
They will target claims forprecluded providers to see if
(03:11):
plans and their delegates arepaying them.
So make sure you watch out forthat one little risk area, which
is the exclusion and preclusionlists.
Second, plans are expected tomaintain at least 10 years of
records on any kind ofinvestigations they've conducted
of providers, and those wouldinclude both in and out of
network providers.
Third, plans have a requirementto not only identify but
(03:35):
recommend providers forexclusion.
And that includes referrals tothe CMS Medic, which is a
contractor that investigatesfraud, waste, and abuse for
Medicare.
Fourth, plans are required tocomply with law enforcement and
regulator requests for fraud,waste, and abuse.
So that's the continuum of whatplans are expected to do.
(03:56):
Judy, do you want to cover whatproviders are responsible for
from a managed career?
SPEAKER_03 (04:00):
Yeah.
So so it's many of theobligations that are assigned to
providers come throughcontracts, not through
regulations, because CMS has itsprivity, which is a word I never
thought I would use again afterlaw school.
I remember thinking about, youknow, like I there were many
(04:22):
things that I heard in lawschool that I didn't see the
relevance for my future life,and privity unbelievably in the
Medicare um sector is veryimportant.
So CMS has privity with theplans in this respect and not
directly with the providers tothose plans.
(04:42):
So plans will will plans undertheir contracts with CMS have
many obligations that they thenpass on to the providers.
So some of the things that Annietalked about, exclusion lists
and preclusion lists, which wecan talk about in some detail
down the line, are obligationsthat are passed down to the
(05:06):
providers to check and make surethat their staff is not on
either of those lists.
State Medicaid programs haveadditional requirements that
they often, well, that that CMSrequires the contracts to
include.
So you can as a as a provider,you can assure that that uh you
(05:29):
are meeting your contractualterms that are coming directly
from CMS, but not for direct umenforcement.
So we're gonna talk about someother things that have evolved,
particularly in light of theLinCare case.
And there's a general obligationon providers to perform services
(05:53):
that are consistent withMedicare guidelines.
Um but the context is differentin some respects because some
services that the plans pay formay not be medically necessary
and reasonable as defined by thestatute.
So they may be supplementalbenefits that that um go beyond
(06:18):
the basic benefits.
So maybe I should talk aboutthose uh concepts for just a
minute.
So, well, first let's talk aboutthe landscape.
So Medicare um Advantage, whichsometimes is called Part C, but
um more technically should becalled Medicare Advantage.
Um allows Medicare beneficiariesto receive benefits from private
(06:42):
plans rather than directly fromCMS.
So in 2024, so last year, 54% ofMedicare beneficiaries were
enrolled in Medicare Advantage,and that was the highest um
percentage ever.
Um from what I hear this year,it's expected to go down some,
(07:04):
and maybe Annie, Annie, whydon't you comment on why
Medicare Advantage enrollmentwould be declining this year?
SPEAKER_01 (07:13):
Yeah, that's a very interesting observation, Judy.
Um, and we're actually enteringinto open enrollment right now,
being that it's October, it justkicked off on October 15th.
So that's an interestingconversation given that you
know, generally the workforce isaging.
Um, the amount of peopleentering into Medicare is
(07:35):
increasing.
Now, the actual percentage ofpeople involved in Medicare
Advantage over original Medicarefee for service is something
worthwhile to watch, right?
That's one of the reasons whyMedicare Advantage is sometimes
seen as different compared tooriginal Medicare fee for
service.
On the original Medicare fee forservice side, you can usually
select your providers, butthere's higher cost sharing on
(07:57):
the Medicare Advantage side.
Usually plans will buy down, sothere's a zero dollar premium
for membership.
But um, in terms of enrollment,it's interesting to see you know
what kind of supplementalbenefits are offered on top of
original Medicare.
How is that going to impactwhether an enrollee decides to
enroll in Medicare Advantage asopposed to traditional Medicare,
(08:18):
or whether they'd like to electa standalone prescription drug
plan?
SPEAKER_03 (08:23):
So we're talking about open enrollment here.
According these statistics arefrom kff.org, KaiserFamily
Foundation.org.
Um, the average Medicarebeneficiary has access to 43
plans as of 2024.
And so if you think about youryour parents or your
grandparents trying to choosebetween plans, it's it's not
(08:46):
easy.
And and um, Annie, maybe youwant to comment on how people do
choose between those plans.
SPEAKER_01 (08:53):
Oh, yeah.
And uh it's definitely alldifficult.
I remember my in-laws recentlyalso had to choose what Medicare
plan they wanted to be a memberof.
And I think what you seenowadays in some of the larger
health plans is they want tocover your entire continuum,
right?
From birth to death, basically.
So starting with commercialinsurance, going into
potentially Medicaid andorMedicare, covering that extent
(09:17):
and really ensuring thatcontinuum of coverage is one of
the priorities of health plansthat cover multiple lines of
business.
But we also have smallerMedicare vantage carriers in the
market, right?
And they usually have networksthat they've built and
cultivated that are specialized,either specific to a population
or to that region, and alsodeveloping tailored benefits for
(09:42):
that population.
So it's interesting to kind ofsee the shift and where people
may decide to enroll.
We know that Medicare PlanFinder, which is on cms.gov, is
one of the ways that many peoplewill choose to do their
research.
And they have recently expandedit this year to include provider
directory, which is a newenhancement as a result of the
(10:05):
final rule.
How that will play out is to bedetermined.
We will see whether thatprovider directory being on
Medicare Plan Finder is going tomake a difference.
There's also the veryinfluential industry of agents
and brokers who help navigateMedicare Advantage options.
And that model is alsocontinuously being challenged by
(10:28):
health plans that are, you know,making some plans
non-commissionable, which hasbeen a very interesting tactic
to encourage or discourageenrollment in some areas.
SPEAKER_03 (10:38):
So as we're recording this, as of this date,
which is October 27, thegovernment is still shut down
and it's not clear when, maybeif, the government will ever
reopen.
And so open enrollment has beenin some question as to how
(10:58):
that's going to proceed.
We also understand that as oftoday, um, some CMS employees
have been recalled uh despitethe shutdown to work on Medicare
enrollment and presumably someother things.
So I would say that all of thatis um a rather fluid situation
at the moment, and we'll see howthat plays out.
(11:19):
Let me just throw out one morestatistic from KFF.org, and
that's the total number ofplans.
So this was as of 2024, wasalmost 4,000 plans.
So we talked about eachbeneficiary has a choice of
approximately 43, but overallthey're almost 4,000.
(11:39):
And as we will talk about um ina few minutes, providers now
need to comply with the terms ofeach plan or face potential
false claims act liability.
And so if you the plans aredifferent in terms of their
requirements and expectations,um, and that's a lot to to keep
(12:02):
track of.
So let's talk a little bit justabout the the basic um structure
of Medicare Advantage.
So the the first requirement isthat the plan has to provide
basic benefits, those are thesame benefits that would be
available to a beneficiary undertraditional Medicare, so parts A
(12:23):
and Part B.
And they have to comply with thetraditional Medicare rules for
each of these.
Um that now includes, and thatthis was clarified in it in the
2024 final rule, which wasissued um in late, I think in
(12:44):
late 2023.
Anyway, uh they it's now beenmade clear by CMS that the basic
benefits have to be provided inthe same manner and same setting
as it would be under traditionalum Medicare.
And that was a big, at leastfrom my perspective, that was a
(13:06):
big clarification.
And I put clarification inquotes because I don't think it
well, it wasn't clear to meprior to that date that uh a
plan could not offer the samebenefits as long as they as long
as the benefits were provided,that perhaps there was some
(13:27):
latitude in terms of how toprovide them, maybe in a lesser
setting, maybe not as aninpatient, um, maybe as anyway.
Now it's clear that they'reexpected to be pretty much
exactly the same as undertraditional Medicare.
They're also what we've referredto in some of our comments
earlier, uh, some plansupplemental benefits.
(13:50):
And those are things that plansoffer to beneficiaries to
distinguish themselves and makea plan a little more attractive.
Annie, do you want to comment onsome of the things that are
included as supplementalbenefits?
SPEAKER_01 (14:06):
Yeah, I think that some of the most common
supplemental benefits you'll seeare typically adding in a dental
benefit or transportation, andthat would be for non-emergency,
since some emergency transportscover under regional Medicare.
I've also seen a lot ofdifferent ones, um, which I will
talk about later, SSBCI, whichis special supplemental benefits
(14:28):
for the chronically ill.
Um, that you do need to have aqualifying chronic disease to
qualify for.
But uh the amount of benefitsthat that opens you up to if you
do qualify is very, veryinteresting because it does need
to be primarily health related.
But we've seen a lot of creativebenefits being incorporated by
plants.
So we'll touch upon that later.
SPEAKER_03 (14:50):
Thank you.
And I can tell you that thathere in the Bay Area in
California, um, there arecommercials that are being run
right now, uh, primarily aboutdental and hearing benefits.
So, so yeah, supplementalbenefits are ways of of
distinguishing plans from eachother.
So let's talk just a little bitabout provider and plan
(15:13):
relations.
I I think particularly after theum the killing in New York of
the United Healthcare umexecutive, that there was a lot
of attention paid to people'sanger over um, and I can say
this because I'm on the providerside, Annie might not, she's on
the plan side.
(15:34):
Um, there was a lot of angeragainst that that surfaced.
Um, I don't think it was causedby, but I think it surfaced with
people who were unhappy aboutthe performance of their plans.
So just um some takeaways here,and if you need these
statistics, you can always emailme and I'll give you the source.
(15:55):
Nearly 15% of all claimssubmitted to private payers for
uh reimbursement are initiallydenied.
And those tend to be for highercost treatments, with the
average denial pegged to chargesof$14,000 and up.
And over half of the denials areultimately overturned.
(16:17):
The average cost incurred byproviders in fighting denials is
for about$44 per claim, meaningthat providers spend$19.7
billion a year just toadjudicate claims with
providers.
So, Annie, I'm going to turn itback to you for some tips on
(16:37):
Medicare advantage compliancefor the plans.
SPEAKER_01 (16:41):
Yeah, this is a really great segue given that
prior discussion about therecent sentiment in the industry
and kind of the large mediascrutiny.
Um, I know that AHIP made a verypublic statement in alliance
with many of its membershipplans about changes they're
making to prior authorizationprocesses, which was one of the
very vocal areas of discontentamong the public.
(17:04):
Um, number of plans signed on tocommitments to make prior
authorization easier forproviders moving forward and
even waiving a lot of priorauthorization requirements for
routine services moving forward.
So that will be one interestingarea that will play out.
Um, so thank you for bringingthat up.
So, going on to Medicare Managedfor plans, there's three areas
(17:26):
I'd like to focus on today thatI think are very relevant to
Medicare Managed state ofcompliance today.
First, kind of what are thechanges in the new
administration and what are theylooking at?
Second, the 2026 final rule.
We know that there was a numberof proposals that were not
finalized.
So those will be interesting tosee how they play out in future
(17:47):
guidance.
And third, there were about nineareas that were finalized in the
recent 2026 final rule that Ijust like to cover today.
So, first, just a quick commenton the new administration.
There were several existingregulations that recently gone
into effect that they weresaying that they were going to
review again currentregulations.
(18:08):
The notice here was that thehealth equity areas took a
special area of focus.
So that was very interesting tome.
There are four areas inparticular where health equity
was one of the areas where theadministration said they'd like
to do some additional research.
First, with the HEI reward orthe health equity index.
(18:29):
This is one of the star ratingmeasures.
Um, it was recently rebranded bythe administration as EHAO for
all or excellent health outcomesfor all.
So kind of rebranded for 2027.
It'll be interesting to see howthat plays out, whether the
calculations will be different.
Second, was that there was arequirement prior to this
(18:50):
administration that all healthplans conduct an annual health
equity analysis of theirutilization management policies
and procedures.
That was actually put on pauseby this administration.
Originally, there was a July1st, 2025 enforcement date.
I did see that some plans wentahead and voluntarily posted
them.
So that's interesting to see.
(19:10):
Essentially, what that requiredwas that people look up their
prior authorization metrics forpercentage of approved and uh
percentage that were denied,just as Judy mentioned earlier.
And they post the overallmetrics compared to those that
are impacted for the low-incomesubsidy and disabled population.
So that kind of a comparison isbeing vetted again by this
(19:33):
administration, currently put onpause, enforcement discretion.
A third area where the currentadministration is looking for
additional review is culturaland linguistic services.
So very big area where there's aset threshold as well as
expectations for applicableintegrated plans to meet the
expectations for their languagesin their specific locales.
(19:55):
The fourth area is qualityimprovement and health risk
assessments.
Specifically, there were newmeasures that were required to
be added that focused on healthequity and social determinants
of health or SDOH.
Those are also currently beingreviewed by this administration,
and we'll just have to see howthe guidance plays out.
Now I'm going to talk about 10areas that were proposed for
(20:17):
2026 that have not beenfinalized in the most recent
guidance.
And these I've seen in thetrends are either number one,
costly, or number two, are veryprotective from an oversight
perspective for enrollees and orfrom a disclosure perspective.
First area is anti-obesitymedication coverage.
(20:38):
So that's one very costly area.
Number two, enhanced guardrailsfor artificial intelligence.
AI, right now, absolutely a veryhot buzz topic.
So those areas for guardrailswould have impacted equitable
access, potentialnon-discrimination, and
disclosure expectations.
(20:58):
Three, I already talked abouthealth equity initiatives, so I
won't linger on that too long.
Four, behavioral health parity.
So that would have implementedstricter protections for
enrollees as well as expandingnetwork adequacy requirements.
Fifth, agent broker oversight.
So this would have greatlyenhanced the amount of oversight
performed on agencies.
(21:20):
They would have to submit theirmaterials to CMS for review, as
well as provide more informationabout low-income status and any
kind of implications ofswitching to traditional
Medicare.
So that is currently on pausegiven that it was not finalized
from the proposal.
Next, pharmacy transparency.
There was a proposal thatpharmacies are able to term
(21:42):
without cause within the sametime frames as health plans.
That also was not finalized.
Formulary placement of generics.
So that would have providedadditional steps to health plans
to check access to generics.
Next, supplemental benefitadministration through debit
cards.
We've seen that that's kind ofgrown in the market where health
plans will issue a debit card tomembers and they'll be able to
(22:05):
access their supplementalbenefits like grocery delivery
or over-the-counter medicationthrough that debit card.
CMS had proposed some guardrailsin place.
Those have not been finalizedyet.
Next is community-based serviceand in-home service contractors,
specifically expanding providerdirectory requirements to
incorporate those networkswithin MA provider directories,
(22:28):
not finalized yet.
Last but not least, Part Dmedication therapy management
programs, which CMS hadoriginally proposed to expand
that list of core chronicdiseases to include dementia and
Alzheimer's, also not finalizedyet.
So it was finalized.
You know, it sounds like a lotwas not finalized yet.
I know there was a secondversion of the rule that was
released recently, but that onlytouched upon provider doctor
(22:51):
requirements.
So what is new is there's nineareas that were finalized.
What I've noticed is theyprimarily focused on reducing
administrative burden or they'vecodified existing expectations.
So really low-risk areas,low-hanging fruit for CMS to
codify.
So I'll go ahead and talk aboutthose nine areas.
(23:11):
First, eliminating cost sharingfor Part D covered insulin and
ACIP covered vaccines.
So that was a given.
Number two, M3P or MedicarePrescription Payment Plan.
This was a new program that wasput in place to allow enrollees
to be able to instead of pay atpoint of sale at the pharmacy
(23:32):
for their medications, theycould just get a monthly invoice
instead and not have to pay upfront.
That is a program that you canelect.
So being the case, CMS wentahead and finalized some of the
operational procedures, such asplans must process such requests
within 24 hours.
That was actually slimming downcompared to original real-time
(23:54):
phone and web processing fromthe original proposed rule.
Also, talking about electionprocedures as well as outreach
requirements, there's beentemplate letters that have been
released for MA plans to use toadminister this program.
Also, what was codified was thatif a member elects for that one
year, they will auto-renew to beelected in that program each
(24:16):
subsequent year.
And they do have a 30-dayopt-out period.
So very important operationalprocesses.
And we'll see, you know, howmany members tend to elect this
option moving forward.
The next couple are really justcodifications of existing
requirements and expectations.
So nothing new to MA plans whohave been accustomed to this
through sub-regulatory guidance.
(24:36):
First area is prescription jugevent or PRD claim submission,
just confirming the time frames,which are you have 30 days to
submit once received, and 90days to adjust, delete, or
reject.
And for the new negotiationprogram, there's a seven-day
process for those PDEs.
Along those lines for thenegotiation program, there's a
(24:58):
transaction facilitator datamodule that is new.
And the acronym for that is theMTFDM.
That does allow network pharmacyagreements to be able to log
into that website and to notonly enroll but also certify,
provide remittance advice, filea complaint or dispute, also
self-report if they have cashflow issues.
(25:20):
So that was one interestingtakeaway.
And they can also check therefund status on that data
module.
Continuing on, I touched uponthis a little bit earlier, but
huge change finalized in therule here was for inpatient
services.
Those are now considered Part Corganization determinations that
are subject to appeals.
So that can occur at any timebefore, during, or after the
(25:43):
inpatient service is performed.
And really, CMS explained in therule that they wanted to prevent
plans from not providing appealrights to providers, and that
this is typical for claimsreviews.
So what this really states isthat there's no more retroactive
denials or downgrades ofinpatient services if the
service was previouslyauthorized by the health plan.
(26:06):
And that even applies ifclinical data was received after
the admission.
So this is really a key area towatch out for.
So compliance officers, makesure you're auditing for that.
Um, there are two exceptions tothat rule, which is if there's
potential fraud or good cause.
Moving on to supplementalbenefits, we touched upon this
earlier as well.
SSBCI, which is the specialsupplemental benefit for the
(26:28):
chronically ill members, do needto qualify for this benefit, and
plans are responsible forverifying eligibility.
And they can do so through avariety of ways.
Now, SSBCI benefits need to beprimarily health related.
So what CMS did in this finalrule is they came up with this
amazing laundry list of what isnot considered primarily health
(26:49):
related.
So they can, in other words, notbe included as SSBCI.
It's a very interesting listhere.
So it does not include cosmeticsurgery, hospital indemnity
insurance, funeral planningexpenses, life insurance,
alcohol, tobacco, cannabis,membership programs.
I always think of like Costco,uh, and non-healthy foods.
So that may be a little, youknow, gray area.
(27:11):
Some people like to eat snacks,uh, borderline, what's healthy,
what's not healthy, maybenegotiable.
Uh, but CMS has clearly statedthat it's not primarily health
related.
What's interesting to notethough is there were some other
areas in the proposed rule whereCMS did not finalize guidance as
now allowable.
And those are areas such as cashor money rebates, gambling
(27:32):
items, firearms, and ammo.
So interesting list right there.
So, with that, there's justthree more areas I wanted to
emphasize that were finalizedrecently in the 2026 final rule.
For dual eligibles, which ismembers that have both Medicare
and Medicaid, CMS is reallytrying to create a more
integrated experience.
(27:53):
So they are now mandating thathealth plans with duals, um, as
they're affectionatelymentioned, have an integrated
member ID card as well as anintegrated health risk
assessment.
Although the health riskassessment portion is postponed
until 1-1-2027 implementation.
Some of the other operationalprocesses most health plans
(28:13):
already know about because CMSis auditing based on these
expectations, such as performinginitial health risk assessment
within 90 days, and then havinga minimum of at least three
non-automated phone calls foroutreach and sending a follow-up
letter through correspondence,unless the member declines to
take that health riskassessment.
Also, it's now codified thathealth plans must update their
(28:34):
individualized care plan ifthere's a change in health
status or transition.
So there's no limit to theamount of times that you need to
update the ICP so long as thatexpectation is met.
So, real quick, risk adjustmentdata.
There is now an update to theHCC definition, which
transferred from disease todiagnosis.
And it is now codified that riskadjustment data is a mandatory
(28:57):
submission.
For medical loss ratio forreporting, this is an
interesting area.
We've seen health plans getenrollment sanctions or even be
closed down due to failure tomeet the MLR.
So a lot of what CMS finalizedhas to do with the calculation
of the medical loss ratio.
What they did finalize is thatyou do exclude the M3P or as we
(29:19):
mentioned earlier, the Medicareprescription payment plan
unsettled balance from thenumerator.
However, there are three areasthat CMS declined to finalize
for the MLR calculations, andthey primarily have to do with
quality improvement.
So one of the areas is providingincentives and bonuses tied to
clinical or quality improvementstandards.
Another area is administrativecost exclusion from quality
(29:40):
improvement activities.
And the third, how the expenseis allocated across lines of
business.
So I know that was a lot ofinteresting information.
I hope you're taking notes.
But as long as you got a coupleof takeaways there, really the
main goal is to understand thatthis is what's been finalized.
This is what may potentiallycome down the line for those
that are proposed.
And here's The focus of the newadministration.
SPEAKER_02 (30:03):
So, Annie, you mentioned a lot that was
finalized, but you alsomentioned a number of items that
were paused.
What happens to those items thatwere paused?
Did they come back?
Did they go away?
Is that for a different day?
SPEAKER_01 (30:21):
A different well, uh, what I would say it's now
become a waiting game, right?
Um, we do expect uh CMS annuallyto re-release the rules through
proposed proposed and finalformat.
So what could happen with thosepast proposals is they could
show up in the 2027 final rule.
They could show up in the 2027proposed rule, they could come
out through HPMS memos.
(30:42):
Either way, I don't think it'sthe end of the story there.
Compliance officers and lawyerswill just need to make sure that
they're checking guidance to seeif those ideas will be
formalized in a differentformat.
SPEAKER_02 (30:56):
Well, in terms of one thing that was on the radar,
but I don't think we've seenyet, is the managed care
compliance guidance coming outof the Office of Inspector
General.
Any word on the timing?
And it's actually hilarious.
SPEAKER_01 (31:19):
It's funny that you mentioned that because
originally uh we were expectingthat to come out um early last
year.
And uh kind of a waiting game.
I know OIG did state that theywere expecting it towards the
end of 2024, still did not comeout.
Um, then there was the change inadministration, so things were
on pause for a bit.
(31:40):
Um now we've not heard anyrumblings yet of when that is
expected to come out.
Judy, do you have furtherinsight on that?
SPEAKER_03 (31:47):
So no, I've heard for several months that it's it
is um done from OIG'sperspective, but just um hasn't
been released yet.
SPEAKER_01 (31:58):
Thank you.
That's helpful.
SPEAKER_02 (32:00):
So go ahead.
I was gonna say, what aboutother enforcement activity or
potential enforcement activityon the MA front, out of OIG or
otherwise?
SPEAKER_01 (32:16):
Yeah, I'm actually going to jump into that segment
in quite a bit, talking aboutsome enforcement actions from
CMS.
Judy, definitely feel free tochime in on OIG.
I know you're about to speak onMA compliance from a provider
perspective.
SPEAKER_03 (32:31):
Yeah, so so I think that there are some um cases
that have been pending for yearsthat may be reaching um a point
or a point of resolution.
I won't name what those are, buthaving to do with the um the
Radvi audits, which is basicallyum a system where Medicare tries
(32:55):
to pay more or CMS tries to paymore for sicker beneficiaries.
And so that was based ondiagnostic codes along the way.
Um CMS feels apparently, CMSactually more appropriately, DOJ
feels that the diagnoses thatwere reported in some cases were
(33:18):
not consistent with thedocumentation.
And so um those there wereaudits initiated and then
investigations, somewhistleblowers were involved,
um, alleging that the diagnosiscodes were basically
overgenerously reported so thatthe plans would receive more
(33:39):
money.
So I think that those are goingto um, if and when, hopefully
soon they resolve, that thosewill provide more guidance in
terms of what um what thegovernment expects in terms of
that, and particularly if thereare CIAs that are attached along
(33:59):
with that, we'll know a bit moreabout what what OIG is expecting
in terms of plan compliance.
Um, but in terms of newenforcement, I think it will be
um I from my perspective, allenforcement right now is a
matter of some question, notjust related to plans, but it's
(34:20):
all a bit unsettled from myperspective.
SPEAKER_02 (34:26):
What about fraud and uh abuse, Judy?
It that seems to be a watch wordthat this administration has
been talking about and focusingon in its various activities.
SPEAKER_03 (34:42):
So I think the question there is how do you
define fraud and abuse?
SPEAKER_02 (34:46):
I agree, I agree.
SPEAKER_03 (34:48):
Everybody is against fraud and abuse, right?
But so what's enforced is fraudand abuse.
I mean, even if you think aboutthe RAD viatas that I was just
talking about, those are largelydocumentation issues in terms
of, I mean, I'm sure there'ssome overt fraud where
(35:08):
somebody's like, you know,somebody just making them up.
Um, but for the most part, Ithink there probably is some
sort of indication of thatcondition, but it isn't
appropriately documented.
So so yeah, fraud and abuse is abig catchword, but what fraud
and abuse means, I think, is thebig question.
(35:30):
Okay, let's talk about what'swhat's new for providers.
Um so one thing, this is notthat new anymore, but I think
it's important to um tounderscore.
So I talked about privityearlier on, and again, this
privity is one of those conceptsI find that governs my career.
(35:50):
Um I'm gonna talk about the60-day refund rule because the
what this is is a statutoryprovision that came out of the
Affordable Care Act in 2010 andrequires that um a certain
category of entities return andreport and refund identified
(36:12):
overpayments.
So people here may be too youngto remember the Affordable Care
Act, and when it was passed,there was a big scramble.
A lot of things were were addedto the bill at the last minute.
Um, a lot of details were notnailed down, definitions,
effective dates, all sorts ofthings, not just in the 60-day
(36:32):
refund rule.
But it has been unclear whetherthe 60-day refund rule applied
to providers under the plans orjust to the plans themselves,
and then providers undertraditional um Medicare.
So CMS, um, after a long sagathat I won't go into, but CMS
(36:53):
issued some new overpaymentrules applicable to parts C and
D.
So Medicare Advantage and PartD, obviously the prescription
drug act or prescription drugbenefit.
So CMS makes clear in this finalrule that it applies only to the
(37:14):
plans and not to the providers.
And so that's a just a veryimportant, is what I'd been
saying all along.
I was glad to see that they thatCMS agreed with me.
So let's talk about some newlitigation though, um, that has
been, from my perspective, areal game changer in terms of
(37:35):
the expectations of providers.
And that's a case involvingLinCare, um, which was a
supplier, is still a supplier ofdurable medical equipment and
equipment that under traditionalMedicare is subject to a rental
cap.
So, what that means is thatbeneficiaries are charged a
(37:56):
rental fee for 36 months orwhatever it is, and after that,
the they basically are deemed toown the equipment, and so it's
not billed any any longer.
So, what Lyncare was alleged tohave done, and this was a
settlement, so no admission ofliability, um what they were
alleged to have done is to havefailed to assure that they
(38:21):
complied with the requirementsof each of the plans to which
they were submitting claims.
And the the plans differedwidely in terms of what they
expected.
So some followed the Medicarerule 36 months and then no
charges after.
Some didn't care, some haddifferent, so it was all over
the place, and Linkare had notum remember I said earlier
(38:47):
there's almost 4,000 plans.
I don't know how many LinCareparticipated in, but there were
a lot, and they had failed topay attention to the difference
in those rules.
They ended up with a bigsettlement and a corporate
integrity agreement for fiveyears.
So, why this case is soimportant is that historically
(39:10):
it had been difficult for thegovernment to figure out how to
assess damages in a false claimsact case that were against a
provider submitting claims to aplan because it's not like
traditional fee for service.
And again, the privity betweenCMS and the plant, it gives
(39:31):
something like a lump sum, youknow, based on the beneficiary's
um conditions, not on thebeneficiary's services.
So it's not like fee forservice, it's like this person
has all these various diagnoses,we'll pay X amount for them.
So this was the first, one ofthe first, and certainly the one
that got the most attention, um,case that basically treated
(39:55):
damages the same as in a fee forservice case.
So that the damages werecalculated as what Lyn care had
billed to um to each plan.
So the settlement was$29million.
Finally got to my notes here.
Um and that came out of theEastern District of Washington.
(40:17):
There was in a corporateintegrity agreement that um
includes a claims review ofclaims submitted to particular
plans.
So um there were a top, the toppaying plans were identified,
and then the claims submitted tothose plans to see if they
complied with the rules thatwere specific to that plan.
(40:40):
So this is something of a gamechanger in terms of saying that
the claims that are submitted tothe plans, even though they are
not directly submitted to andpaid by CMS, will be subject to
the False Claims Act.
There are also, we've talkedabout the RADB audits, there are
(41:03):
also um, or is also at least onecase.
I think there are a few othersthat that are settlements, where
the provider has been um uhactually in one case charged
criminally with overstating thediagnoses.
And then um there are other somecivil cases causing False Claims
(41:26):
Act to be submitted.
Uh so OIG, DOJ is uh goingdirectly against the uh the
providers um for compliance withthe RAD V obligations.
So Annie, I'm gonna turn it backto you for administrative
enforcement discussions.
SPEAKER_01 (41:47):
Yes.
Um if you don't know thisalready, bookmark the CMS
Enforcement Action websitebecause there's some really good
case studies there of what thehealth plans are doing that CMS
is not happy about.
And they are in fact taking someaction, such as issuing civil
monetary penalties andorenrollment sanctions.
So what I've done is I've kindof taken a look and CMS, I've
(42:10):
noticed, tends to update thisevery couple of cycles when they
issue their enforcement letters.
The most recent batch deal withthree areas.
So 2021 financial audits and2024 program audits, as well as
financial solvency.
So what I saw for the 2021financial audit findings were
there's three main areas whereCMS uh dinged health plans.
(42:33):
First, for failing to reprocesslow-income subsidy within 45
days, and that typically resultsin increased cost sharing for
the members.
So there are three health plansthat were issued that finding
and issued civil monetarypenalties.
Second, where the health planscharged more than the maximum
out-of-pocket limit.
So, again, that's someout-of-pocket beneficiary
(42:54):
impact.
There were four health plansthat were cited for that.
Third, one health planovercharged on Part C services.
So you can kind of see a themehere through the financial
audits.
They're really looking to seewas there any beneficiary
impact?
Do they pay more out of pocketthan they should have?
And we're going to take a youknow a civil monetary penalty
out of the health plan forfailing to catch that and for
(43:16):
hitting the member from theaspect.
I do know that they also expectyou to refund the member as a
health plan.
If they do identify these kindof issues through a program
audit or a financial audit, theywill expect the health plan to
perform an impact analysis andidentify all members that are
potentially impacted, even thoseoutside of contracts that were
the scope of the audit.
So that's a little key tip rightthere.
(43:38):
Second is 2024 program auditareas of enforcement.
And there were really fiveconditions that were cited that
resulted in penalties to healthplans.
First, with inappropriaterejection of formulary
medication due to eligibilityerrors.
Now, that was a new one that Isaw this year.
Four health plans had thisissue.
(43:58):
Typically, if it's related tothe PBM, what CMS will do is
they'll audit the rest of theplans that use that same PBM to
see if this is an issuewidespread amongst that
delegated entity.
So it looks like here this was acostly mistake, right?
Obviously, the eligibility fellresulting in a formulary change,
that would mean that the memberwould get an inappropriate
(44:20):
rejection of that medication atpoint of sale.
So one of the high risk areas.
Second was failure to initiate acoverage request and/or
misrouting a request.
Again, very, very serious impactbeing that when members call the
plan, that's already the lastresort.
And if they're requesting thatthey need access to a service,
(44:40):
whether it's pre-service orpost-service are repaid up
front, there's an expectationfrom CMS that health plans
process that requestimmediately, that there's no
delay.
And they do follow the stricttime frames for processing the
request.
So two health plans were citedfor that and issued fines.
Third, inappropriate rejectionof a transition supply.
So this is typically whenthere's a change in the contract
(45:03):
year because there's appropriaterejection there.
That's also a high risk area forhealth plans and ensuring that
that transition of 90 days isprocessed.
And recently that was copiedover from the part D side over
to part C, being that there's a90-day transition.
One other health plan was citedfor authorizations not carried
(45:25):
over when they change their PBM.
That's another high-risk areathat CMS always monitors for.
If the member had anauthorization in place, they
should be held harmless.
That should carry over even ifthe health plan switches PBMs.
Last but not least, and this isinteresting data, being that
PACE audits were new.
PACE is a specialized programunder Medicare Advantage,
requires an on-site center toadminister services.
(45:49):
There were three health plansthat were cited for their PACE
plans in failure to provideservices and track, document,
and monitor across differentsettings.
So that was a new condition thatI saw.
It looks like CMS went ahead andtook some action on it from a
civil monetary penaltyperspective.
Very interesting to watch there.
The last category was forfinancial solvency.
(46:10):
Typically, we know financialsolvency is an area that is
monitored by states as opposedto the federal.
So usually the state will catchthe issue.
And then CMS on the back end,because of financial solvency
issues like failure to payclaims, issues with paying the
provider network, that willresult in an enrollment
sanction.
So there was one health plan inthis past cycle of enforcement
(46:32):
letters that was suspended dueto that financial solvency
issue.
So I know we've covered a lot ofground today.
I'm going to hand it back toJudy to provide some ending
remarks and our conclusion.
SPEAKER_03 (46:45):
So thank you, Annie.
And I just want to do somesubstantive conclusions.
This is obviously an area offocus, this uh compliance for
Medicare Advantage, both forplans and providers.
The dollar amounts are verylarge.
Um, the Trump administration hasexpressed support for Medicare
(47:06):
Advantage, but again, as when wetalked about uh what is fraud
and abuse and how that's definedand how that implicates uh the
whole scene, support will alsobe um, I'm sure, a term that um
many people are disputing.
So the expectations for bothplans and providers seem to be
(47:30):
increasing and have higher risksin terms of non-compliance.
We're still awaiting the OIG'sguidance and very hopeful that
that will provide words ofwisdom.
Um, and with that, I want tothank you for sticking with us
today and turn it back to Kathyfor some closing um remarks.
SPEAKER_02 (47:51):
Thanks, Judy.
And Annie, before we tune out,do you have any final words from
the plan side or are we a wrapfor today?
SPEAKER_01 (48:02):
Yeah, I this is why I love the field of compliance
and healthcare a lot.
Everything is constantlychanging.
Uh, but what I've really learnedthroughout this industry is
regardless of what size healthplan you work at, whether small,
medium, or large, theexpectations are always the
same.
So even though health plans havedifferent ways of executing uh
how they comply with theseexpectations, it's always
(48:25):
important to stay abreast of theregulations and OIG and CMS's
expectations in regards to them.
And the best way to find out isreading those enforcement
actions, staying up to date onguidance, going through audits
and staying plugged into theindustry.
SPEAKER_02 (48:41):
Thank you all for joining us today.
Thank you, Annie.
Thank you, Judy, for sharing abit of what you talked about at
the 2025 HLA annual meeting.
And we hope you all considerjoining us in New York City in
2026 for the annual meeting atthe end of June through the
(49:05):
first of July.
And maybe we'll be fortunate tohear from Annie and Judy again
as to what's happening with MAfor plans and providers in 2026
and heading into 2027.
SPEAKER_00 (49:20):
Bye all.org and stay updated on breaking healthcare
(49:42):
industry news from the majormedia outlets with AHLA's Health
Law Daily Podcast, exclusivelyfor AHLA comprehensive members.
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
This episode of AHLA Speaking of Health Law is
brought to you by AHLA membersand donors like you.
For more information, visitAmerican Health Law.org.
SPEAKER_02 (00:17):
Hello, AHLA members.
Welcome to today's podcast.
I'm Kathy Rowe.
I am an attorney with Health LawConsultancy in Chicago, and I am
the chair of the Payers Plansand Managed Care Practice Group.
Today I'm bringing you twospeakers who presented on a
(00:40):
managed care topic at thissummer's AHLA annual meeting.
Annie, Judy, you want tointroduce yourself?
Hi everyone.
SPEAKER_01 (00:51):
My name's Annie Shea, and I have 16 years of
experience in Medicare AdvantageCompliance.
I am also on this year's AHLAAnnual Meeting Planning
Committee.
So very excited to look forwardto what new topics and speakers
will be coming our way.
And I'm also former chair of thePayers Plans Managed Care
Practice Group, same as Kathy.
Judy, you want to take it away?
SPEAKER_03 (01:13):
Sure.
So my name is Judy Waltz.
I'm a partner with Foley andLardner in the San Francisco
office.
I chair our health carepractice, which is about 60
dedicated healthcare lawyers.
The first part of my career Ispent with the federal
government in an office that hasnow been decommissioned, so to
speak, with in the San FranciscoRegional Office of the General
(01:37):
Counsel.
I had the pleasure of speakingwith Annie this summer at AHLA
and would encourage everyone toattend the annual meeting.
It's a very fun, not just uheducational event.
And I am a former chair of theHLA regulatory accreditation and
payment practice group, which isum one that I would highly
(02:01):
recommend, as well as the PPMC.
So, Annie, are you ready to jumpin?
SPEAKER_01 (02:08):
Yeah, let's get started.
So, what we'd like to covertoday is really how Medicare
vanish compliance impacts plansand providers.
So, where we'd like to start iswhose responsibility is it,
anyways?
And the short answer to thatquestion is it's both of our
responsibilities.
And I'm kind of speaking fromthe plan perspective because
that's where my career started.
(02:30):
So, health plans have fourprimary areas in responsibility
for vetting providers.
First is monthly screening.
So that requires checkingagainst the OIG exclusion list
as well as the GSA and the CMSpreclusion list if you're
involved in Medicare.
So that's the first requirement.
(02:50):
And one of the tricky areas isif you do delegate claims
processing to an entity, youalso need to make sure that they
are checking that monthlyexclusion list.
CMS will actually vet thisthrough their financial audits.
They will target claims forprecluded providers to see if
(03:11):
plans and their delegates arepaying them.
So make sure you watch out forthat one little risk area, which
is the exclusion and preclusionlists.
Second, plans are expected tomaintain at least 10 years of
records on any kind ofinvestigations they've conducted
of providers, and those wouldinclude both in and out of
network providers.
Third, plans have a requirementto not only identify but
(03:35):
recommend providers forexclusion.
And that includes referrals tothe CMS Medic, which is a
contractor that investigatesfraud, waste, and abuse for
Medicare.
Fourth, plans are required tocomply with law enforcement and
regulator requests for fraud,waste, and abuse.
So that's the continuum of whatplans are expected to do.
(03:56):
Judy, do you want to cover whatproviders are responsible for
from a managed career?
SPEAKER_03 (04:00):
Yeah.
So so it's many of theobligations that are assigned to
providers come throughcontracts, not through
regulations, because CMS has itsprivity, which is a word I never
thought I would use again afterlaw school.
I remember thinking about, youknow, like I there were many
(04:22):
things that I heard in lawschool that I didn't see the
relevance for my future life,and privity unbelievably in the
Medicare um sector is veryimportant.
So CMS has privity with theplans in this respect and not
directly with the providers tothose plans.
(04:42):
So plans will will plans undertheir contracts with CMS have
many obligations that they thenpass on to the providers.
So some of the things that Annietalked about, exclusion lists
and preclusion lists, which wecan talk about in some detail
down the line, are obligationsthat are passed down to the
(05:06):
providers to check and make surethat their staff is not on
either of those lists.
State Medicaid programs haveadditional requirements that
they often, well, that that CMSrequires the contracts to
include.
So you can as a as a provider,you can assure that that uh you
(05:29):
are meeting your contractualterms that are coming directly
from CMS, but not for direct umenforcement.
So we're gonna talk about someother things that have evolved,
particularly in light of theLinCare case.
And there's a general obligationon providers to perform services
(05:53):
that are consistent withMedicare guidelines.
Um but the context is differentin some respects because some
services that the plans pay formay not be medically necessary
and reasonable as defined by thestatute.
So they may be supplementalbenefits that that um go beyond
(06:18):
the basic benefits.
So maybe I should talk aboutthose uh concepts for just a
minute.
So, well, first let's talk aboutthe landscape.
So Medicare um Advantage, whichsometimes is called Part C, but
um more technically should becalled Medicare Advantage.
Um allows Medicare beneficiariesto receive benefits from private
(06:42):
plans rather than directly fromCMS.
So in 2024, so last year, 54% ofMedicare beneficiaries were
enrolled in Medicare Advantage,and that was the highest um
percentage ever.
Um from what I hear this year,it's expected to go down some,
(07:04):
and maybe Annie, Annie, whydon't you comment on why
Medicare Advantage enrollmentwould be declining this year?
SPEAKER_01 (07:13):
Yeah, that's a very interesting observation, Judy.
Um, and we're actually enteringinto open enrollment right now,
being that it's October, it justkicked off on October 15th.
So that's an interestingconversation given that you
know, generally the workforce isaging.
Um, the amount of peopleentering into Medicare is
(07:35):
increasing.
Now, the actual percentage ofpeople involved in Medicare
Advantage over original Medicarefee for service is something
worthwhile to watch, right?
That's one of the reasons whyMedicare Advantage is sometimes
seen as different compared tooriginal Medicare fee for
service.
On the original Medicare fee forservice side, you can usually
select your providers, butthere's higher cost sharing on
(07:57):
the Medicare Advantage side.
Usually plans will buy down, sothere's a zero dollar premium
for membership.
But um, in terms of enrollment,it's interesting to see you know
what kind of supplementalbenefits are offered on top of
original Medicare.
How is that going to impactwhether an enrollee decides to
enroll in Medicare Advantage asopposed to traditional Medicare,
(08:18):
or whether they'd like to electa standalone prescription drug
plan?
SPEAKER_03 (08:23):
So we're talking about open enrollment here.
According these statistics arefrom kff.org, KaiserFamily
Foundation.org.
Um, the average Medicarebeneficiary has access to 43
plans as of 2024.
And so if you think about youryour parents or your
grandparents trying to choosebetween plans, it's it's not
(08:46):
easy.
And and um, Annie, maybe youwant to comment on how people do
choose between those plans.
SPEAKER_01 (08:53):
Oh, yeah.
And uh it's definitely alldifficult.
I remember my in-laws recentlyalso had to choose what Medicare
plan they wanted to be a memberof.
And I think what you seenowadays in some of the larger
health plans is they want tocover your entire continuum,
right?
From birth to death, basically.
So starting with commercialinsurance, going into
potentially Medicaid andorMedicare, covering that extent
(09:17):
and really ensuring thatcontinuum of coverage is one of
the priorities of health plansthat cover multiple lines of
business.
But we also have smallerMedicare vantage carriers in the
market, right?
And they usually have networksthat they've built and
cultivated that are specialized,either specific to a population
or to that region, and alsodeveloping tailored benefits for
(09:42):
that population.
So it's interesting to kind ofsee the shift and where people
may decide to enroll.
We know that Medicare PlanFinder, which is on cms.gov, is
one of the ways that many peoplewill choose to do their
research.
And they have recently expandedit this year to include provider
directory, which is a newenhancement as a result of the
(10:05):
final rule.
How that will play out is to bedetermined.
We will see whether thatprovider directory being on
Medicare Plan Finder is going tomake a difference.
There's also the veryinfluential industry of agents
and brokers who help navigateMedicare Advantage options.
And that model is alsocontinuously being challenged by
(10:28):
health plans that are, you know,making some plans
non-commissionable, which hasbeen a very interesting tactic
to encourage or discourageenrollment in some areas.
SPEAKER_03 (10:38):
So as we're recording this, as of this date,
which is October 27, thegovernment is still shut down
and it's not clear when, maybeif, the government will ever
reopen.
And so open enrollment has beenin some question as to how
(10:58):
that's going to proceed.
We also understand that as oftoday, um, some CMS employees
have been recalled uh despitethe shutdown to work on Medicare
enrollment and presumably someother things.
So I would say that all of thatis um a rather fluid situation
at the moment, and we'll see howthat plays out.
(11:19):
Let me just throw out one morestatistic from KFF.org, and
that's the total number ofplans.
So this was as of 2024, wasalmost 4,000 plans.
So we talked about eachbeneficiary has a choice of
approximately 43, but overallthey're almost 4,000.
(11:39):
And as we will talk about um ina few minutes, providers now
need to comply with the terms ofeach plan or face potential
false claims act liability.
And so if you the plans aredifferent in terms of their
requirements and expectations,um, and that's a lot to to keep
(12:02):
track of.
So let's talk a little bit justabout the the basic um structure
of Medicare Advantage.
So the the first requirement isthat the plan has to provide
basic benefits, those are thesame benefits that would be
available to a beneficiary undertraditional Medicare, so parts A
(12:23):
and Part B.
And they have to comply with thetraditional Medicare rules for
each of these.
Um that now includes, and thatthis was clarified in it in the
2024 final rule, which wasissued um in late, I think in
(12:44):
late 2023.
Anyway, uh they it's now beenmade clear by CMS that the basic
benefits have to be provided inthe same manner and same setting
as it would be under traditionalum Medicare.
And that was a big, at leastfrom my perspective, that was a
(13:06):
big clarification.
And I put clarification inquotes because I don't think it
well, it wasn't clear to meprior to that date that uh a
plan could not offer the samebenefits as long as they as long
as the benefits were provided,that perhaps there was some
(13:27):
latitude in terms of how toprovide them, maybe in a lesser
setting, maybe not as aninpatient, um, maybe as anyway.
Now it's clear that they'reexpected to be pretty much
exactly the same as undertraditional Medicare.
They're also what we've referredto in some of our comments
earlier, uh, some plansupplemental benefits.
(13:50):
And those are things that plansoffer to beneficiaries to
distinguish themselves and makea plan a little more attractive.
Annie, do you want to comment onsome of the things that are
included as supplementalbenefits?
SPEAKER_01 (14:06):
Yeah, I think that some of the most common
supplemental benefits you'll seeare typically adding in a dental
benefit or transportation, andthat would be for non-emergency,
since some emergency transportscover under regional Medicare.
I've also seen a lot ofdifferent ones, um, which I will
talk about later, SSBCI, whichis special supplemental benefits
(14:28):
for the chronically ill.
Um, that you do need to have aqualifying chronic disease to
qualify for.
But uh the amount of benefitsthat that opens you up to if you
do qualify is very, veryinteresting because it does need
to be primarily health related.
But we've seen a lot of creativebenefits being incorporated by
plants.
So we'll touch upon that later.
SPEAKER_03 (14:50):
Thank you.
And I can tell you that thathere in the Bay Area in
California, um, there arecommercials that are being run
right now, uh, primarily aboutdental and hearing benefits.
So, so yeah, supplementalbenefits are ways of of
distinguishing plans from eachother.
So let's talk just a little bitabout provider and plan
(15:13):
relations.
I I think particularly after theum the killing in New York of
the United Healthcare umexecutive, that there was a lot
of attention paid to people'sanger over um, and I can say
this because I'm on the providerside, Annie might not, she's on
the plan side.
(15:34):
Um, there was a lot of angeragainst that that surfaced.
Um, I don't think it was causedby, but I think it surfaced with
people who were unhappy aboutthe performance of their plans.
So just um some takeaways here,and if you need these
statistics, you can always emailme and I'll give you the source.
(15:55):
Nearly 15% of all claimssubmitted to private payers for
uh reimbursement are initiallydenied.
And those tend to be for highercost treatments, with the
average denial pegged to chargesof$14,000 and up.
And over half of the denials areultimately overturned.
(16:17):
The average cost incurred byproviders in fighting denials is
for about$44 per claim, meaningthat providers spend$19.7
billion a year just toadjudicate claims with
providers.
So, Annie, I'm going to turn itback to you for some tips on
(16:37):
Medicare advantage compliancefor the plans.
SPEAKER_01 (16:41):
Yeah, this is a really great segue given that
prior discussion about therecent sentiment in the industry
and kind of the large mediascrutiny.
Um, I know that AHIP made a verypublic statement in alliance
with many of its membershipplans about changes they're
making to prior authorizationprocesses, which was one of the
very vocal areas of discontentamong the public.
(17:04):
Um, number of plans signed on tocommitments to make prior
authorization easier forproviders moving forward and
even waiving a lot of priorauthorization requirements for
routine services moving forward.
So that will be one interestingarea that will play out.
Um, so thank you for bringingthat up.
So, going on to Medicare Managedfor plans, there's three areas
(17:26):
I'd like to focus on today thatI think are very relevant to
Medicare Managed state ofcompliance today.
First, kind of what are thechanges in the new
administration and what are theylooking at?
Second, the 2026 final rule.
We know that there was a numberof proposals that were not
finalized.
So those will be interesting tosee how they play out in future
(17:47):
guidance.
And third, there were about nineareas that were finalized in the
recent 2026 final rule that Ijust like to cover today.
So, first, just a quick commenton the new administration.
There were several existingregulations that recently gone
into effect that they weresaying that they were going to
review again currentregulations.
(18:08):
The notice here was that thehealth equity areas took a
special area of focus.
So that was very interesting tome.
There are four areas inparticular where health equity
was one of the areas where theadministration said they'd like
to do some additional research.
First, with the HEI reward orthe health equity index.
(18:29):
This is one of the star ratingmeasures.
Um, it was recently rebranded bythe administration as EHAO for
all or excellent health outcomesfor all.
So kind of rebranded for 2027.
It'll be interesting to see howthat plays out, whether the
calculations will be different.
Second, was that there was arequirement prior to this
(18:50):
administration that all healthplans conduct an annual health
equity analysis of theirutilization management policies
and procedures.
That was actually put on pauseby this administration.
Originally, there was a July1st, 2025 enforcement date.
I did see that some plans wentahead and voluntarily posted
them.
So that's interesting to see.
(19:10):
Essentially, what that requiredwas that people look up their
prior authorization metrics forpercentage of approved and uh
percentage that were denied,just as Judy mentioned earlier.
And they post the overallmetrics compared to those that
are impacted for the low-incomesubsidy and disabled population.
So that kind of a comparison isbeing vetted again by this
(19:33):
administration, currently put onpause, enforcement discretion.
A third area where the currentadministration is looking for
additional review is culturaland linguistic services.
So very big area where there's aset threshold as well as
expectations for applicableintegrated plans to meet the
expectations for their languagesin their specific locales.
(19:55):
The fourth area is qualityimprovement and health risk
assessments.
Specifically, there were newmeasures that were required to
be added that focused on healthequity and social determinants
of health or SDOH.
Those are also currently beingreviewed by this administration,
and we'll just have to see howthe guidance plays out.
Now I'm going to talk about 10areas that were proposed for
(20:17):
2026 that have not beenfinalized in the most recent
guidance.
And these I've seen in thetrends are either number one,
costly, or number two, are veryprotective from an oversight
perspective for enrollees and orfrom a disclosure perspective.
First area is anti-obesitymedication coverage.
(20:38):
So that's one very costly area.
Number two, enhanced guardrailsfor artificial intelligence.
AI, right now, absolutely a veryhot buzz topic.
So those areas for guardrailswould have impacted equitable
access, potentialnon-discrimination, and
disclosure expectations.
(20:58):
Three, I already talked abouthealth equity initiatives, so I
won't linger on that too long.
Four, behavioral health parity.
So that would have implementedstricter protections for
enrollees as well as expandingnetwork adequacy requirements.
Fifth, agent broker oversight.
So this would have greatlyenhanced the amount of oversight
performed on agencies.
(21:20):
They would have to submit theirmaterials to CMS for review, as
well as provide more informationabout low-income status and any
kind of implications ofswitching to traditional
Medicare.
So that is currently on pausegiven that it was not finalized
from the proposal.
Next, pharmacy transparency.
There was a proposal thatpharmacies are able to term
(21:42):
without cause within the sametime frames as health plans.
That also was not finalized.
Formulary placement of generics.
So that would have providedadditional steps to health plans
to check access to generics.
Next, supplemental benefitadministration through debit
cards.
We've seen that that's kind ofgrown in the market where health
plans will issue a debit card tomembers and they'll be able to
(22:05):
access their supplementalbenefits like grocery delivery
or over-the-counter medicationthrough that debit card.
CMS had proposed some guardrailsin place.
Those have not been finalizedyet.
Next is community-based serviceand in-home service contractors,
specifically expanding providerdirectory requirements to
incorporate those networkswithin MA provider directories,
(22:28):
not finalized yet.
Last but not least, Part Dmedication therapy management
programs, which CMS hadoriginally proposed to expand
that list of core chronicdiseases to include dementia and
Alzheimer's, also not finalizedyet.
So it was finalized.
You know, it sounds like a lotwas not finalized yet.
I know there was a secondversion of the rule that was
released recently, but that onlytouched upon provider doctor
(22:51):
requirements.
So what is new is there's nineareas that were finalized.
What I've noticed is theyprimarily focused on reducing
administrative burden or they'vecodified existing expectations.
So really low-risk areas,low-hanging fruit for CMS to
codify.
So I'll go ahead and talk aboutthose nine areas.
(23:11):
First, eliminating cost sharingfor Part D covered insulin and
ACIP covered vaccines.
So that was a given.
Number two, M3P or MedicarePrescription Payment Plan.
This was a new program that wasput in place to allow enrollees
to be able to instead of pay atpoint of sale at the pharmacy
(23:32):
for their medications, theycould just get a monthly invoice
instead and not have to pay upfront.
That is a program that you canelect.
So being the case, CMS wentahead and finalized some of the
operational procedures, such asplans must process such requests
within 24 hours.
That was actually slimming downcompared to original real-time
(23:54):
phone and web processing fromthe original proposed rule.
Also, talking about electionprocedures as well as outreach
requirements, there's beentemplate letters that have been
released for MA plans to use toadminister this program.
Also, what was codified was thatif a member elects for that one
year, they will auto-renew to beelected in that program each
(24:16):
subsequent year.
And they do have a 30-dayopt-out period.
So very important operationalprocesses.
And we'll see, you know, howmany members tend to elect this
option moving forward.
The next couple are really justcodifications of existing
requirements and expectations.
So nothing new to MA plans whohave been accustomed to this
through sub-regulatory guidance.
(24:36):
First area is prescription jugevent or PRD claim submission,
just confirming the time frames,which are you have 30 days to
submit once received, and 90days to adjust, delete, or
reject.
And for the new negotiationprogram, there's a seven-day
process for those PDEs.
Along those lines for thenegotiation program, there's a
(24:58):
transaction facilitator datamodule that is new.
And the acronym for that is theMTFDM.
That does allow network pharmacyagreements to be able to log
into that website and to notonly enroll but also certify,
provide remittance advice, filea complaint or dispute, also
self-report if they have cashflow issues.
(25:20):
So that was one interestingtakeaway.
And they can also check therefund status on that data
module.
Continuing on, I touched uponthis a little bit earlier, but
huge change finalized in therule here was for inpatient
services.
Those are now considered Part Corganization determinations that
are subject to appeals.
So that can occur at any timebefore, during, or after the
(25:43):
inpatient service is performed.
And really, CMS explained in therule that they wanted to prevent
plans from not providing appealrights to providers, and that
this is typical for claimsreviews.
So what this really states isthat there's no more retroactive
denials or downgrades ofinpatient services if the
service was previouslyauthorized by the health plan.
(26:06):
And that even applies ifclinical data was received after
the admission.
So this is really a key area towatch out for.
So compliance officers, makesure you're auditing for that.
Um, there are two exceptions tothat rule, which is if there's
potential fraud or good cause.
Moving on to supplementalbenefits, we touched upon this
earlier as well.
SSBCI, which is the specialsupplemental benefit for the
(26:28):
chronically ill members, do needto qualify for this benefit, and
plans are responsible forverifying eligibility.
And they can do so through avariety of ways.
Now, SSBCI benefits need to beprimarily health related.
So what CMS did in this finalrule is they came up with this
amazing laundry list of what isnot considered primarily health
(26:49):
related.
So they can, in other words, notbe included as SSBCI.
It's a very interesting listhere.
So it does not include cosmeticsurgery, hospital indemnity
insurance, funeral planningexpenses, life insurance,
alcohol, tobacco, cannabis,membership programs.
I always think of like Costco,uh, and non-healthy foods.
So that may be a little, youknow, gray area.
(27:11):
Some people like to eat snacks,uh, borderline, what's healthy,
what's not healthy, maybenegotiable.
Uh, but CMS has clearly statedthat it's not primarily health
related.
What's interesting to notethough is there were some other
areas in the proposed rule whereCMS did not finalize guidance as
now allowable.
And those are areas such as cashor money rebates, gambling
(27:32):
items, firearms, and ammo.
So interesting list right there.
So, with that, there's justthree more areas I wanted to
emphasize that were finalizedrecently in the 2026 final rule.
For dual eligibles, which ismembers that have both Medicare
and Medicaid, CMS is reallytrying to create a more
integrated experience.
(27:53):
So they are now mandating thathealth plans with duals, um, as
they're affectionatelymentioned, have an integrated
member ID card as well as anintegrated health risk
assessment.
Although the health riskassessment portion is postponed
until 1-1-2027 implementation.
Some of the other operationalprocesses most health plans
(28:13):
already know about because CMSis auditing based on these
expectations, such as performinginitial health risk assessment
within 90 days, and then havinga minimum of at least three
non-automated phone calls foroutreach and sending a follow-up
letter through correspondence,unless the member declines to
take that health riskassessment.
Also, it's now codified thathealth plans must update their
(28:34):
individualized care plan ifthere's a change in health
status or transition.
So there's no limit to theamount of times that you need to
update the ICP so long as thatexpectation is met.
So, real quick, risk adjustmentdata.
There is now an update to theHCC definition, which
transferred from disease todiagnosis.
And it is now codified that riskadjustment data is a mandatory
(28:57):
submission.
For medical loss ratio forreporting, this is an
interesting area.
We've seen health plans getenrollment sanctions or even be
closed down due to failure tomeet the MLR.
So a lot of what CMS finalizedhas to do with the calculation
of the medical loss ratio.
What they did finalize is thatyou do exclude the M3P or as we
(29:19):
mentioned earlier, the Medicareprescription payment plan
unsettled balance from thenumerator.
However, there are three areasthat CMS declined to finalize
for the MLR calculations, andthey primarily have to do with
quality improvement.
So one of the areas is providingincentives and bonuses tied to
clinical or quality improvementstandards.
Another area is administrativecost exclusion from quality
(29:40):
improvement activities.
And the third, how the expenseis allocated across lines of
business.
So I know that was a lot ofinteresting information.
I hope you're taking notes.
But as long as you got a coupleof takeaways there, really the
main goal is to understand thatthis is what's been finalized.
This is what may potentiallycome down the line for those
that are proposed.
And here's The focus of the newadministration.
SPEAKER_02 (30:03):
So, Annie, you mentioned a lot that was
finalized, but you alsomentioned a number of items that
were paused.
What happens to those items thatwere paused?
Did they come back?
Did they go away?
Is that for a different day?
SPEAKER_01 (30:21):
A different well, uh, what I would say it's now
become a waiting game, right?
Um, we do expect uh CMS annuallyto re-release the rules through
proposed proposed and finalformat.
So what could happen with thosepast proposals is they could
show up in the 2027 final rule.
They could show up in the 2027proposed rule, they could come
out through HPMS memos.
(30:42):
Either way, I don't think it'sthe end of the story there.
Compliance officers and lawyerswill just need to make sure that
they're checking guidance to seeif those ideas will be
formalized in a differentformat.
SPEAKER_02 (30:56):
Well, in terms of one thing that was on the radar,
but I don't think we've seenyet, is the managed care
compliance guidance coming outof the Office of Inspector
General.
Any word on the timing?
And it's actually hilarious.
SPEAKER_01 (31:19):
It's funny that you mentioned that because
originally uh we were expectingthat to come out um early last
year.
And uh kind of a waiting game.
I know OIG did state that theywere expecting it towards the
end of 2024, still did not comeout.
Um, then there was the change inadministration, so things were
on pause for a bit.
(31:40):
Um now we've not heard anyrumblings yet of when that is
expected to come out.
Judy, do you have furtherinsight on that?
SPEAKER_03 (31:47):
So no, I've heard for several months that it's it
is um done from OIG'sperspective, but just um hasn't
been released yet.
SPEAKER_01 (31:58):
Thank you.
That's helpful.
SPEAKER_02 (32:00):
So go ahead.
I was gonna say, what aboutother enforcement activity or
potential enforcement activityon the MA front, out of OIG or
otherwise?
SPEAKER_01 (32:16):
Yeah, I'm actually going to jump into that segment
in quite a bit, talking aboutsome enforcement actions from
CMS.
Judy, definitely feel free tochime in on OIG.
I know you're about to speak onMA compliance from a provider
perspective.
SPEAKER_03 (32:31):
Yeah, so so I think that there are some um cases
that have been pending for yearsthat may be reaching um a point
or a point of resolution.
I won't name what those are, buthaving to do with the um the
Radvi audits, which is basicallyum a system where Medicare tries
(32:55):
to pay more or CMS tries to paymore for sicker beneficiaries.
And so that was based ondiagnostic codes along the way.
Um CMS feels apparently, CMSactually more appropriately, DOJ
feels that the diagnoses thatwere reported in some cases were
(33:18):
not consistent with thedocumentation.
And so um those there wereaudits initiated and then
investigations, somewhistleblowers were involved,
um, alleging that the diagnosiscodes were basically
overgenerously reported so thatthe plans would receive more
(33:39):
money.
So I think that those are goingto um, if and when, hopefully
soon they resolve, that thosewill provide more guidance in
terms of what um what thegovernment expects in terms of
that, and particularly if thereare CIAs that are attached along
(33:59):
with that, we'll know a bit moreabout what what OIG is expecting
in terms of plan compliance.
Um, but in terms of newenforcement, I think it will be
um I from my perspective, allenforcement right now is a
matter of some question, notjust related to plans, but it's
(34:20):
all a bit unsettled from myperspective.
SPEAKER_02 (34:26):
What about fraud and uh abuse, Judy?
It that seems to be a watch wordthat this administration has
been talking about and focusingon in its various activities.
SPEAKER_03 (34:42):
So I think the question there is how do you
define fraud and abuse?
SPEAKER_02 (34:46):
I agree, I agree.
SPEAKER_03 (34:48):
Everybody is against fraud and abuse, right?
But so what's enforced is fraudand abuse.
I mean, even if you think aboutthe RAD viatas that I was just
talking about, those are largelydocumentation issues in terms
of, I mean, I'm sure there'ssome overt fraud where
(35:08):
somebody's like, you know,somebody just making them up.
Um, but for the most part, Ithink there probably is some
sort of indication of thatcondition, but it isn't
appropriately documented.
So so yeah, fraud and abuse is abig catchword, but what fraud
and abuse means, I think, is thebig question.
(35:30):
Okay, let's talk about what'swhat's new for providers.
Um so one thing, this is notthat new anymore, but I think
it's important to um tounderscore.
So I talked about privityearlier on, and again, this
privity is one of those conceptsI find that governs my career.
(35:50):
Um I'm gonna talk about the60-day refund rule because the
what this is is a statutoryprovision that came out of the
Affordable Care Act in 2010 andrequires that um a certain
category of entities return andreport and refund identified
(36:12):
overpayments.
So people here may be too youngto remember the Affordable Care
Act, and when it was passed,there was a big scramble.
A lot of things were were addedto the bill at the last minute.
Um, a lot of details were notnailed down, definitions,
effective dates, all sorts ofthings, not just in the 60-day
(36:32):
refund rule.
But it has been unclear whetherthe 60-day refund rule applied
to providers under the plans orjust to the plans themselves,
and then providers undertraditional um Medicare.
So CMS, um, after a long sagathat I won't go into, but CMS
(36:53):
issued some new overpaymentrules applicable to parts C and
D.
So Medicare Advantage and PartD, obviously the prescription
drug act or prescription drugbenefit.
So CMS makes clear in this finalrule that it applies only to the
(37:14):
plans and not to the providers.
And so that's a just a veryimportant, is what I'd been
saying all along.
I was glad to see that they thatCMS agreed with me.
So let's talk about some newlitigation though, um, that has
been, from my perspective, areal game changer in terms of
(37:35):
the expectations of providers.
And that's a case involvingLinCare, um, which was a
supplier, is still a supplier ofdurable medical equipment and
equipment that under traditionalMedicare is subject to a rental
cap.
So, what that means is thatbeneficiaries are charged a
(37:56):
rental fee for 36 months orwhatever it is, and after that,
the they basically are deemed toown the equipment, and so it's
not billed any any longer.
So, what Lyncare was alleged tohave done, and this was a
settlement, so no admission ofliability, um what they were
alleged to have done is to havefailed to assure that they
(38:21):
complied with the requirementsof each of the plans to which
they were submitting claims.
And the the plans differedwidely in terms of what they
expected.
So some followed the Medicarerule 36 months and then no
charges after.
Some didn't care, some haddifferent, so it was all over
the place, and Linkare had notum remember I said earlier
(38:47):
there's almost 4,000 plans.
I don't know how many LinCareparticipated in, but there were
a lot, and they had failed topay attention to the difference
in those rules.
They ended up with a bigsettlement and a corporate
integrity agreement for fiveyears.
So, why this case is soimportant is that historically
(39:10):
it had been difficult for thegovernment to figure out how to
assess damages in a false claimsact case that were against a
provider submitting claims to aplan because it's not like
traditional fee for service.
And again, the privity betweenCMS and the plant, it gives
(39:31):
something like a lump sum, youknow, based on the beneficiary's
um conditions, not on thebeneficiary's services.
So it's not like fee forservice, it's like this person
has all these various diagnoses,we'll pay X amount for them.
So this was the first, one ofthe first, and certainly the one
that got the most attention, um,case that basically treated
(39:55):
damages the same as in a fee forservice case.
So that the damages werecalculated as what Lyn care had
billed to um to each plan.
So the settlement was$29million.
Finally got to my notes here.
Um and that came out of theEastern District of Washington.
(40:17):
There was in a corporateintegrity agreement that um
includes a claims review ofclaims submitted to particular
plans.
So um there were a top, the toppaying plans were identified,
and then the claims submitted tothose plans to see if they
complied with the rules thatwere specific to that plan.
(40:40):
So this is something of a gamechanger in terms of saying that
the claims that are submitted tothe plans, even though they are
not directly submitted to andpaid by CMS, will be subject to
the False Claims Act.
There are also, we've talkedabout the RADB audits, there are
(41:03):
also um, or is also at least onecase.
I think there are a few othersthat that are settlements, where
the provider has been um uhactually in one case charged
criminally with overstating thediagnoses.
And then um there are other somecivil cases causing False Claims
(41:26):
Act to be submitted.
Uh so OIG, DOJ is uh goingdirectly against the uh the
providers um for compliance withthe RAD V obligations.
So Annie, I'm gonna turn it backto you for administrative
enforcement discussions.
SPEAKER_01 (41:47):
Yes.
Um if you don't know thisalready, bookmark the CMS
Enforcement Action websitebecause there's some really good
case studies there of what thehealth plans are doing that CMS
is not happy about.
And they are in fact taking someaction, such as issuing civil
monetary penalties andorenrollment sanctions.
So what I've done is I've kindof taken a look and CMS, I've
(42:10):
noticed, tends to update thisevery couple of cycles when they
issue their enforcement letters.
The most recent batch deal withthree areas.
So 2021 financial audits and2024 program audits, as well as
financial solvency.
So what I saw for the 2021financial audit findings were
there's three main areas whereCMS uh dinged health plans.
(42:33):
First, for failing to reprocesslow-income subsidy within 45
days, and that typically resultsin increased cost sharing for
the members.
So there are three health plansthat were issued that finding
and issued civil monetarypenalties.
Second, where the health planscharged more than the maximum
out-of-pocket limit.
So, again, that's someout-of-pocket beneficiary
(42:54):
impact.
There were four health plansthat were cited for that.
Third, one health planovercharged on Part C services.
So you can kind of see a themehere through the financial
audits.
They're really looking to seewas there any beneficiary
impact?
Do they pay more out of pocketthan they should have?
And we're going to take a youknow a civil monetary penalty
out of the health plan forfailing to catch that and for
(43:16):
hitting the member from theaspect.
I do know that they also expectyou to refund the member as a
health plan.
If they do identify these kindof issues through a program
audit or a financial audit, theywill expect the health plan to
perform an impact analysis andidentify all members that are
potentially impacted, even thoseoutside of contracts that were
the scope of the audit.
So that's a little key tip rightthere.
(43:38):
Second is 2024 program auditareas of enforcement.
And there were really fiveconditions that were cited that
resulted in penalties to healthplans.
First, with inappropriaterejection of formulary
medication due to eligibilityerrors.
Now, that was a new one that Isaw this year.
Four health plans had thisissue.
(43:58):
Typically, if it's related tothe PBM, what CMS will do is
they'll audit the rest of theplans that use that same PBM to
see if this is an issuewidespread amongst that
delegated entity.
So it looks like here this was acostly mistake, right?
Obviously, the eligibility fellresulting in a formulary change,
that would mean that the memberwould get an inappropriate
(44:20):
rejection of that medication atpoint of sale.
So one of the high risk areas.
Second was failure to initiate acoverage request and/or
misrouting a request.
Again, very, very serious impactbeing that when members call the
plan, that's already the lastresort.
And if they're requesting thatthey need access to a service,
(44:40):
whether it's pre-service orpost-service are repaid up
front, there's an expectationfrom CMS that health plans
process that requestimmediately, that there's no
delay.
And they do follow the stricttime frames for processing the
request.
So two health plans were citedfor that and issued fines.
Third, inappropriate rejectionof a transition supply.
So this is typically whenthere's a change in the contract
(45:03):
year because there's appropriaterejection there.
That's also a high risk area forhealth plans and ensuring that
that transition of 90 days isprocessed.
And recently that was copiedover from the part D side over
to part C, being that there's a90-day transition.
One other health plan was citedfor authorizations not carried
(45:25):
over when they change their PBM.
That's another high-risk areathat CMS always monitors for.
If the member had anauthorization in place, they
should be held harmless.
That should carry over even ifthe health plan switches PBMs.
Last but not least, and this isinteresting data, being that
PACE audits were new.
PACE is a specialized programunder Medicare Advantage,
requires an on-site center toadminister services.
(45:49):
There were three health plansthat were cited for their PACE
plans in failure to provideservices and track, document,
and monitor across differentsettings.
So that was a new condition thatI saw.
It looks like CMS went ahead andtook some action on it from a
civil monetary penaltyperspective.
Very interesting to watch there.
The last category was forfinancial solvency.
(46:10):
Typically, we know financialsolvency is an area that is
monitored by states as opposedto the federal.
So usually the state will catchthe issue.
And then CMS on the back end,because of financial solvency
issues like failure to payclaims, issues with paying the
provider network, that willresult in an enrollment
sanction.
So there was one health plan inthis past cycle of enforcement
(46:32):
letters that was suspended dueto that financial solvency
issue.
So I know we've covered a lot ofground today.
I'm going to hand it back toJudy to provide some ending
remarks and our conclusion.
SPEAKER_03 (46:45):
So thank you, Annie.
And I just want to do somesubstantive conclusions.
This is obviously an area offocus, this uh compliance for
Medicare Advantage, both forplans and providers.
The dollar amounts are verylarge.
Um, the Trump administration hasexpressed support for Medicare
(47:06):
Advantage, but again, as when wetalked about uh what is fraud
and abuse and how that's definedand how that implicates uh the
whole scene, support will alsobe um, I'm sure, a term that um
many people are disputing.
So the expectations for bothplans and providers seem to be
(47:30):
increasing and have higher risksin terms of non-compliance.
We're still awaiting the OIG'sguidance and very hopeful that
that will provide words ofwisdom.
Um, and with that, I want tothank you for sticking with us
today and turn it back to Kathyfor some closing um remarks.
SPEAKER_02 (47:51):
Thanks, Judy.
And Annie, before we tune out,do you have any final words from
the plan side or are we a wrapfor today?
SPEAKER_01 (48:02):
Yeah, I this is why I love the field of compliance
and healthcare a lot.
Everything is constantlychanging.
Uh, but what I've really learnedthroughout this industry is
regardless of what size healthplan you work at, whether small,
medium, or large, theexpectations are always the
same.
So even though health plans havedifferent ways of executing uh
how they comply with theseexpectations, it's always
(48:25):
important to stay abreast of theregulations and OIG and CMS's
expectations in regards to them.
And the best way to find out isreading those enforcement
actions, staying up to date onguidance, going through audits
and staying plugged into theindustry.
SPEAKER_02 (48:41):
Thank you all for joining us today.
Thank you, Annie.
Thank you, Judy, for sharing abit of what you talked about at
the 2025 HLA annual meeting.
And we hope you all considerjoining us in New York City in
2026 for the annual meeting atthe end of June through the
(49:05):
first of July.
And maybe we'll be fortunate tohear from Annie and Judy again
as to what's happening with MAfor plans and providers in 2026
and heading into 2027.
SPEAKER_00 (49:20):
Bye all.org and stay updated on breaking healthcare
(49:42):
industry news from the majormedia outlets with AHLA's Health
Law Daily Podcast, exclusivelyfor AHLA comprehensive members.
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
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