January 16, 2026 • 42 mins
Daniel Hettich, Partner, King & Spalding LLP, Emily Cook, Partner, McDermott Will & Schulte, Elizabeth Lippincott, Managing Member, Strategic Health Law, and Susan Banks, Partner, Holland & Knight LLP, discuss some of the latest trends and developments in the world of Medicare, as well as what to expect in 2026. They cover issues related to Part A, Part C (Medicare Advantage), fraud and abuse, and appeals and arbitration. Daniel was Faculty Chair, and Emily, Elizabeth, and Susan were Faculty members, of AHLA’s new Medicare 101 Course.
Watch this episode: https://www.youtube.com/watch?v=kQ5q_WxdItg
Learn more about AHLA’s Medicare 101 Course: https://www.americanhealthlaw.org/education-events/101-online-courses/medicare-101
Essential Legal Updates, Now in Audio
AHLA's popular Health Law Daily email newsletter is now a daily podcast, exclusively for AHLA Comprehensive members. Get all your health law news from the major media outlets on this podcast! To subscribe and add this private podcast feed to your podcast app, go to americanhealthlaw.org/dailypodcast.
Stay At the Forefront of Health Legal Education
Learn more about AHLA and the educational resources available to the health law community at https://www.americanhealthlaw.org/.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_01 (00:04):
This episode of AHLA Speaking of Health Law is
brought to you by AHLA membersand donors like you.
For more information, visitAmericanHealthlaw.org.
SPEAKER_00 (00:16):
Hello everyone.
I'm Dan Heddock.
I'm a partner in King andSwalding's healthcare practice
resident in Washington, D.C.
I'm uh hosting this podcastbecause I was faculty chair of
uh AHLA's Medicare 101 on demandcourse.
Um I'm very excited to be joinedby three of the faculty, three
other faculty members uh forthat call course.
(00:39):
If you haven't seen it yet, it'suh a 10-module um 101 course, as
as the name indicates, that youcan take at your own pace.
And I'll let each of the otherfaculty members introduce
themselves, but I'll just say byway of overview that we're gonna
be covering um the part A of theMedicare program, which covers
uh inpatient, uh hospitalinpatient care.
(01:02):
Uh part C, also known asMedicare Advantage.
Uh, we have the faculty memberwho did that module with us.
And then uh Medicare fraud andabuse, obviously an important
topic.
Um and then finally, my modulewe'll talk about just a little
bit.
I handled the uh appeals andarbitration um area, so areas of
controversy within Medicare.
But with that, I'll turn it overto my other faculty members.
(01:24):
Maybe Emily, could you uh kickus off, introduce yourself?
SPEAKER_02 (01:28):
Great, thank you, Dan.
I'm Emily Cook.
I'm a partner with McDermottWill and Schulte in our Los
Angeles office, and have beenworking for quite some time with
providers who receive paymentfrom Medicare, and I'm excited
to talk with uh all of you todayabout those coverage and uh
other rules.
SPEAKER_00 (01:47):
Thanks, Emily.
Elizabeth?
SPEAKER_03 (01:49):
Yeah, hi.
Um thanks, Dan.
I'm Elizabeth Lippincott.
I'm managing member of StrategicHealth Law, and I have been
doing um managed care work for25 years and founded this law
firm 20 years ago, and have beenum focusing primarily on
government managed care plans,particularly Medicare Advantage
and Part D for that time period.
SPEAKER_04 (02:11):
Susan?
Thanks, Dan.
I am Susan Banks.
I'm a partner at Holland Knightin the Denver office, and I
specialize in Medicarereimbursement and payment
issues.
And I had the opportunity todeliver the module at the med on
the 101 course on Medicare fraudand abuse topics.
So I'm looking forward todiscussing it with you all.
SPEAKER_00 (02:33):
Great.
Well, I'll ask my firstquestion, I think will be the
same for all of you.
I think for 101 it makes sense.
If each of you could give uskind of a nutshell of your
topic, obviously, you know,there's I know there's a lot to
be said on each of those topics,but really what a lawyer in this
space would need to know to beto be competent.
Um Emily, you handled the thePart A um module about Medicare
(02:56):
inpatient.
Maybe I'll start with you.
SPEAKER_02 (02:58):
Sure.
Medicare Part A generally isconsidered to be the component
of the Medicare program thatcovers what are often referred
to as facility services.
So primarily when you think ofPart A, most people are going to
think of general acute careinpatient hospital services.
Although it is uh quite a bitmore broad, Medicare Part A also
(03:19):
covers home health, hospice,end-stage renal disease, and
actually quite a few otherservices.
So while the general uh approachto Part A is that it is covering
hospital inpatient services, itis uh quite a bit more broad
than that.
SPEAKER_00 (03:35):
Great.
Thank you, Emily.
Um Elizabeth, maybe can you tellus about Part C?
What is what do folks need toknow to be competent about
Medicare Part C?
SPEAKER_03 (03:44):
Yeah, I think the most important thing in Medicare
Part C is just to know what theuniverse of regulations and
guidance is and to be aware ofthe primacy of subregulatory
guidance and um to know howimportant it is.
Um and and it we use the wordguidance, but because for the
(04:04):
Medicare Advantageorganizations, they are required
in their contracts to complywith guidance.
Guidance is really a misnomer.
They're requirements for theplan and for their that's flowed
down to their vendors andproviders.
So really knowing how to accessthe voluminous manuals as
updated memos, um, QAs,reporting guidance, just
(04:29):
thousands of pages ofinstructions is probably the
most important thing.
So at least you know where tolook and know that whatever
random question you might have,there's probably an answer
somewhere or somehow it'saddressed.
There's a decent chance.
It's just so highly regulated.
Um, it's it's pretty intense interms of the requirements and
(04:54):
how granular they are.
SPEAKER_00 (04:56):
Right.
Susan, what what would youranswer be for fraud and abuse?
SPEAKER_04 (05:00):
You know, I Medicare fraud and abuse or federal
healthcare program fraud andabuse broadly.
Um, a lot of it is is uh basedon it, it's it's grounded in a
lot of the same types ofmaterials that Elizabeth was
just referencing, right?
These are the broad federal andstate law analogs, statutory
regulatory frameworks thatpolice uh improper business
(05:22):
contact conduct in thehealthcare arena, right?
So everything from um uhover-billing, uh improper
billing, billing the wrongservices, uh, to providing too
many services, medicallyunnecessary services, or uh
worthless services, right?
When when services fall below acertain threshold so that
(05:44):
they're not even good andvaluable services.
Um so the fraud and abuse lawsare um broad.
The penalties associated withviolating them are um can be
truly enormous.
Everything from um you knowoverpayment penalties and and
damages associated with billingincorrectly to um potential
(06:10):
stays in prison for for moresignificant conduct that
violates the laws.
So, you know, to Elizabeth'spoint, in such a highly
regulated industry, I thinkwhere we see things go wrong,
even even the most well-meaningproviders and suppliers get it
wrong sometimes.
And and the folks who are perpotentially newer, newer
entrants into the market, who'vetransitioned from other business
(06:31):
lines maybe into the healthcarespace, and there's there's a bit
of a learning curve.
There's there's a lot to beaware of in in the healthcare
arena that uh may not beintuitive always.
SPEAKER_00 (06:41):
Right.
Well, I'll answer my ownquestion for the appeals and
arbitration area.
I think um obviously there's alot that could be said, um, as I
alluded to, but I think one ofthe things, one of the
fundamental aspects to be awareof is that each of the different
parts of Medicare, and we kindof alluded to it, maybe we
should have said a little bitmore about it, but part A is
(07:01):
only says primarily inpatient,part B is more outpatient
physician services, part C isthe managed care with the
private companies, part D, whichwe won't be talking too much
about today, but focuses onprescription drugs.
And each of those areas havetheir own appeal mechanism.
Um part A generally goes throughif a hospital has a complaint
(07:22):
about how Medicare isreimbursing for inpatient
services, those usually wouldrun through the provider
reimbursement review board.
That's where I spend most of mytime.
Um Part C, for example, is anentirely different animal.
Usually it's governed bycontractual language and usually
more arbitration, as uhElizabeth alluded to.
Um Part D, another unique uhanimal.
(07:43):
Actually, there's been a recentappeal mechanism for when
there's disputes between drugmanufacturers and uh uh
typically hospitals who receivediscounts, the 340B program.
Um so I think maybe onefundamental takeaway for folks
there is that there's adifferent, then there's also the
um DAB and ALJ appeal processfor individual services.
(08:08):
So I think at the highest level,folks should be aware that there
are different uh appealmechanisms, uh sometimes very
different, for each of thoseprograms.
If we have a little bit timelater, I might talk a little bit
more about again part A appeals,which is where I spend my time.
But Emily, I did want to go backto you.
I know you alluded to alreadythat, you know, as we said a
couple of times now, part A isprimarily inpatient care, but
(08:32):
encompasses other stuff likehospice, et cetera.
Who determines what is and isnot covered by Part A, by
Medicare Part A?
SPEAKER_02 (08:41):
Sure.
So there is a hierarchy of uhwho determines what is covered.
And I think uh building on whatuh Elizabeth was mentioning
about guidance, um, in the PartA space, uh, we always start
with the statute.
Uh so we will first look to seewhat Congress has said about
what is covered by Medicare andwhat isn't.
(09:02):
Uh they don't say a lot aboutit.
Most of the information thatcomes from the statute is at a
very high level and does notprovide the necessary
granularity to understand in anyparticular instance what is or
is not covered.
And then we look at theregulations.
And while the regulations, asyou would expect, are somewhat
(09:23):
more detailed, particularly inthe Medicare Part A space.
They provide very little insightto whether a particular service,
and typically the part A we'retalking about a stay rather than
an individual service.
So a particular patient's day ata facility is covered.
So then we look to the guidance,uh, and we may get some more
information in the guidance inthe Medicare space across all
(09:44):
parts of Medicare.
The guidance is something thatwe use very, very frequently and
more frequently than thestatutes or the regulations.
Um, and in part A, we also seequite a lot of information
coming from the Medicareadministrative contractors.
Those are companies that havecontracted with the Centers for
(10:05):
Medicare and Medicaid Servicesto actually administer the
Medicare program.
And they themselves issueguidance that provides
information about coverage,particularly what are known as
national coverage determinationsand local coverage
determinations.
So in any given instance, whenwe are trying to determine
(10:25):
whether a particular part, aservice or stay is covered,
there is uh quite a bit ofmaterial that needs to be
reviewed, again, starting withthe statute, ending with uh the
Medicare administrativecontractor guidance.
SPEAKER_00 (10:40):
Great.
Elizabeth, I'm curious if youhave thoughts.
Um, I mean based on what Emilysaid, and I think there's often
a lot of confusion about what'ssimilar with part C compared to
part A, what's different, howmuch of that that Emily
described with the statuteregulations policy, does that
apply at all under Part C?
Um, how is Part C different fromPart A?
How is it the same?
SPEAKER_03 (11:02):
It's very similar in terms of the you know tiering of
statutory um authorityregulations.
And I would add, um it's it'sreally important in reviewing
the regulations that you sort ofdo the regulatory history and
look back at the we've got a uman index of it's incredible how
many times these have beenupdated.
(11:22):
And there's a lot of goodcommentary in there that I think
of as guidance or kind ofregulatory history, and then um
the manuals, the part C manuals,and then another wrinkle that
does tie back to what Emily wastalking about with the um
national and local coveragedeterminations in original
Medicare.
So for Medicare Advantage plans,they are um underwritten and
(11:45):
administered by privateinsurance companies.
Um, however, the floor forbenefits is what is covered by
um original Medicare.
So for inpatient, it's part A.
And CMS has clarified in thelast few years, this has always
been the case, but they'vethey've sort of added to their
interpretation that coveragerules from Part A have to be
(12:08):
adhered to by Part C MedicareAdvantage plans.
Payment rules generally speakingdo not.
So the payment for in-networkproviders is um determined in
the contract between the Part Cplan and the provider, in this
case, the hospital.
However, um according to CMS,more and more things that we
(12:31):
historically thought of aspayment rules, not necessarily
applicable, are now beingtreated as coverage rules if
they um determine someone'saccess to um coverage in an
inpatient setting.
So there is overlap, and I wouldsay over the last couple of
years, that overlap has grownbecause of that um emphasis from
(12:52):
the regulators.
SPEAKER_00 (12:54):
Right.
And Susan, I imagine there aretimes where folks don't follow
all the statutes, regulations,and policies that uh Emily and
Elizabeth alluded to.
Uh is that where the FalseClaims Act uh kind of kicks in?
SPEAKER_04 (13:11):
Yes, often, right?
The False Claims Act remains oneof the biggest enforcement tools
and most prevalent enforcementtools that are used by um by
regulators in this space.
It's um it's it's I was gonnasay unique.
I don't know that it's unique,but but it's an extraordinarily
broad statute, right, with awide reach in terms of conduct.
(13:33):
And it's been um deployed withgreat uh success from the
government's perspective, right,in in the healthcare regulatory
space because of the nexus withclaims submitted to the federal
government.
So so what the False Claims Actprohibits, just very very
broadly and generally, right, itpolices the submission of
(13:55):
improper false claims to thefederal government for payment.
And so in the healthcare conductcontext, sorry, a claim is is, I
think it's it's definedintuitively mostly, right?
For for most purposes, it's ait's a bill for services, an
invoice for services, a claimfor payment, you you submit a
document that um initiates apayment by the government.
(14:17):
And what the False Claims Actprohibits is the knowing
submission of false claims.
So if there's material,materially false information
either on the face of the claim,you billed for a knee
replacement and should havebilled for a hip replacement, um
materially false and faciallyincorrect information on the
(14:38):
claim.
Or if by merely submitting thatclaim you're certifying, you're
making a representation toMedicare in this case that you
have followed all the paymentrules necessary to qualify for
that payment, that's that'scalled an implied certification,
right, of compliance.
If you've submitted the claimand you know it's incorrect,
which means you have actualknowledge that it's incorrect,
(15:01):
or you are um acting indeliberate ignorance of whether
or not it's incorrect, um, orum, gosh, I'm forgetting the
third one.
Y'all help me out.
Actually, actual knowledge,deliberate ignorance, or
reckless disregard.
SPEAKER_03 (15:17):
Reckless disregard.
SPEAKER_04 (15:18):
Reckless disregard, um, which is actually probably
the one of the most common onesthat comes up all the time.
So that's funny that it shouldslip my mind.
But if you have you are notpaying attention to, right,
whether in the extent to whichthat uh certification of
compliance, the information onthat claim is correct or
incorrect, you've submitted afalse claim.
(15:39):
And so what false claims actlitigation comes down to always
is the quality of the guidance,right?
Whether it's the claim is isprohibited on the face of the
statute, on the face of aregulation that was duly
promulgated by the agency thatthat prohibits the claim at
(16:00):
issue, or states a complianceobligation that you know you
didn't meet and yet yousubmitted the claim anyway, um,
or or even down in thesubregulatory context, right?
So to the the extent to whichand it's fascinating to dig to
dig deeper down in there, butthe extent to which there was
other guidance that's that's notduly promulgated in a
(16:21):
regulation, but it either isdeserving of deference or or it
caused, gave you reason to knowthat your claim would was
incorrect in one way or another.
Um violation of those guidelinescan also form the basis of a
false claim.
It's it's super fact specific.
It always is.
Um I'll I'll pause there.
(16:43):
There's more I could say onthat, but but I want to let
other folks jump in becausethere's some really neat
differences between the part Aand the Part C context.
SPEAKER_03 (16:49):
You made a really good point, Susan, in your
comments earlier about howchallenging it can be to enter
this area of industry from otherindustries because it's so
regulated and you're dealingwith federal dollars and federal
programs.
And I I'll go out on a limb andsay the biggest culture shock is
for people that have um grown upin the tech industry, which is
(17:13):
one of the least, it's notcompletely unregulated, but it's
one of the least regulated areasof our economy outside that, you
know, when you're not in thehealth context.
Coming from tech to health, um,and I'm not saying that's bad or
good, it has pros and cons, andit's probably why we've had such
incredible innovation here, butcoming from, you know, a tech
environment into healthcare,especially in the Medicare
(17:34):
space, you've got what you'vejust described with the False
Claims Act, and also what youtouched on, which is the
interaction with theanti-kickback statute, that if
you're submitting claims, you'reaffirming that you don't have
any kickback statute violationsin place.
It's a criminal law and it's nottotally intuitive.
(17:55):
And there are things that mightnot feel morally wrong and might
be normal business practices inother industries in terms of
exchange of value that can getyou sent to jail in this space.
So it really is a very differentuniverse.
And um, these concepts are soimportant for people to
understand um when they're doingbusiness, you know, before they
(18:17):
even have a before they evenknow they have a question.
SPEAKER_02 (18:20):
I think that comes up a lot for me with folks who
have uh ideas about innovativecare delivery models.
And as you noted, there arequite a lot of uh, particularly
at this point in time, emerginginnovative care delivery models,
but there are also scenarios inwhich uh someone will come up
with what they believe to be agreat idea about how to deliver
(18:43):
health care that no one has comeup with before.
And uh I will say that uh moreoften than not, it is not that
someone has not come up with itbefore, it's that it's illegal.
And communicating that to folkswho do not regularly work in
this space can be verychallenging.
SPEAKER_04 (19:02):
It's really true.
And I think the kickback statutethat you mentioned, Elizabeth,
we haven't really gotten into itand we sure can in greater
depth.
But that's one of the areas thatI think is most fascinating
because some of the activity,right, this notion of
incentivizing business, right?
It just makes good businesssense.
You come from any otherindustry, commercial industry in
the US.
Um, uh, and it of course I'lloffer you a discount if you'll
(19:26):
buy more of my product, right?
But as soon as you throw infederal healthcare program
dollars into the mix, and whatthat incentive is, what that
discount means is that you'regoing to order more of my item
or service that's reimbursableby a federal health care
program.
Well, now you're incentivizingit now, they call it a kickback,
right?
Because what you'reincentivizing are referrals, and
(19:48):
and the one who's gonna pay forit is the federal government.
And so there's a law to toprohibit what otherwise would
just make good business sense.
And I think, yeah.
SPEAKER_03 (19:57):
I have an anecdote.
I was in a business coachingprogram for a while.
With all people from alldifferent kinds of businesses.
And um, this great guy was adentist.
He had a very, very high-end umprivate paid dental practice.
And something that he did is hewould offer, he would have an
auto-detailer come and um detailhis patient's cars when they
(20:18):
came for their appointments.
And I was like, you don't takeany federal money, do you?
He's like, no, no.
I'm like, never, ever, everenroll with any state or federal
friend.
Just don't.
It's you're not cut out for it,you know.
But it's that kind of thing.
SPEAKER_00 (20:36):
Elizabeth, you have to tell me that dentist's name.
I wouldn't mind having mydetailed getting my teeth.
Um well, you you guys alluded toit a little bit already, but
maybe, maybe Susan, this ismaybe most in your wheelhouse.
Can you talk to us a little bitmore about the penalties?
I know Elizabeth alluded tojail.
Obviously, that's you knowunusual and probably like the
worst, but what are thepenalties associated with
(20:56):
violations of um either theanti-kickback or the um false
claims act?
Obviously, they're different.
Yeah, maybe just give us a senseof what the what the stakes are.
SPEAKER_04 (21:05):
Absolutely.
Well, I'll I'll start with thethe false claims act penalties.
Um those penalties are based onand they're calculated on the
basis of the amount of re theamount of remuneration that you
received, the amount of paymentyou received in exchange for the
false claim, right?
So, so um baseline damages areare this single damages, right?
(21:27):
Would be the amount of moneythat you that you got paid for
all the claims that were foundto have been false in violation
of the statute.
False claims that penalties canbe up to treble damages, so
three times that amount, andwhich which sounds like a lot,
and it is a lot.
But then also uh you can getcharged um penalties on top of
the trouble damages, and thepenalties are per claim damages,
(21:49):
which means for every claim thatis submitted, um you can get an
additional penalty amountbetween, I think it's around
15,000 minimum to 30,000, closeto 30,000 maximum at the moment.
And I don't have the exactnumbers in front of me, but it's
significant.
I mean, so imagine, imagine amedically unnecessary UTI
(22:11):
testing um issue, and you youend up getting uh certainly the
trouble damages amount that theamount you got paid for these
UTI uh urine tests that weremore than more than should have
been billed, right?
Maybe you were testing too manyservices or testing too many
patients.
Um, so you've got troubledamages, but then every single
(22:32):
individual claim for aurinalysis will then generate
either the minimum,$15,000 perup to about$30,000 per.
And those per claim penalties umreally balloon very quickly, and
they can they can rapidlyeclipse the trouble damages
amount.
Um, and some of these some ofthese settlements and and
(22:52):
assessed penalties are areastronomical.
SPEAKER_00 (22:55):
Um so that's Elizabeth, are there analogs in
the Part C context?
I mean, if if or because it'sprivate contracts, is it
different?
SPEAKER_03 (23:04):
Yes.
A lot of the um well, the mosthigh risk area in Medicare
Advantage is risk adjustment,which we explain the
fundamentals of in the in thecourse, the Part C module.
But um essentially health memberspecific health information
diagnosis codes are submitted bythe plans.
(23:25):
They originate with providersgenerally.
They're submitted by the plansto the federal government, and
um for certain um high costdiagnoses, you receive more
money every month from thefederal government.
Those are subject to audit bythe government, as well as um
they are a lucrative form of umwhistleblower litigation claims,
(23:47):
um, and they're uh hotlyrecruited by um whistleblower
plaintiffs lawyers, and we haveseen settlements in the tens of
millions of dollars and evenbeyond.
Um, so uh those can be the thedefendants in those can be both
the plans that are um submittingthose claims directly and also
(24:10):
their vendors and theirhealthcare providers that are
submitting data and diagnosesthat are used to determine
federal payment.
Um, so it's a risk area forproviders as well, especially if
they're taking risk undervalue-based contracts with
Medicare Advantage plans.
They can be defendants in thoselawsuits as well.
(24:31):
And and it's really um thingthat makes it um so risky is the
um, I don't think this is theonly motive for for
whistleblowers, frankly, butthere is a very strong profit
motive where they can take homeuh 15 to 30 percent of the
settlement or the damages.
So um strong incentive for themto bring these lawsuits, the
(24:54):
Department of Justice can umjoin them or not, or intervene
or not.
Um, but yeah, it to answer yourquestion, yes, definitely
there's risk.
SPEAKER_00 (25:03):
And I will say Oh yeah, please.
I was gonna ask you so go ahead.
SPEAKER_02 (25:08):
Sure.
So I will say that um asElizabeth alluded to, there can
be whistleblower actions in theMedicare space.
And that is another good sourceof information about the types
of activities that could get uha provider, if not in trouble
with the government, uh, subjectto a significant amount of
(25:29):
administrative and financialburden.
One of the very interestingaspects about the Medicare
program uh and its relationshipto the Federal False Claims Act
and the uh key TAM orwhistleblower provisions is that
a whistleblower doesn'tnecessarily need to actually be
(25:50):
correct in their allegationsthat a provider has violated the
law and submitted false claims.
Uh, that can still create asignificant amount of burden for
providers.
Typically, um, whistleblowerswill uh be motivated uh by the
potential financial recovery inthose cases and will only bring
(26:12):
cases where they think that theyare going to ultimately prevail
and uh obtain uh the at leastcost of their litigation and
some additional uh money on topof that.
But I would say I think all ofus probably deal with scenarios
where there are incrediblyspecious allegations or that the
underlying uh violation is notan actual violation, and it
(26:35):
doesn't really matter in termsof having to defend those cases.
It can cost you as much todefend a case that is completely
unwarranted as it does to defenda case that actually has some
potential uh violations in theallegations.
SPEAKER_00 (26:53):
I'll I'll take just another moment to talk about the
um kind of similar ideas in theappeals context, which I think
is different.
A lot of what we've beendiscussing is kind of defensive.
Um usually providers are um onthe defensive end of being
accused of uh violating someprovision.
On the appeals side, it's almostthe reverse of that, where um
(27:16):
sometimes providers think thatthe government itself hasn't
reimbursed them the way Congressor the way the statute says they
should be reimbursed, or the waythe agency's own regulation um
says they should be uhreimbursed, for example.
Um and there is this mechanismfor hospitals or other providers
to to appeal thosedeterminations and challenge the
(27:37):
agency's uh reimbursementdecisions.
Um and I'm focusing again, Isaid at the outset, like each of
the different parts of theMedicare have different appeal
mechanisms.
This is more on the part Ainpatient side.
Um but in those cases, if ahospital thinks that CMS is not
reimbursing as the statute ofregulation um requires, they can
(27:59):
bring these affirmative appealsthat start off at the
administrative level, eventuallygoes to the federal court, some
even to the Supreme Court.
Um I'll just mention one.
This is my area, so it's it's itmight be nerdy, but but I like
it.
Um so I find it fascinating.
But I'll focus just on oneaspect uh because I think it is
important, an important seachange, um, which is this recent
(28:22):
Supreme Court decision,historically for the past 40
years up until two years ago.
Um, any type of challenge likethat, the agency got a very
significant deference, you know,in its its interpretation of the
statute or or its ownregulation.
Um particularly the questions ofstatutory interpretation.
The Supreme Court in a casecalled Chevron had said, unless
(28:44):
the agency's interpretation wasactively unreasonable, it didn't
have to be the best.
As long as it wasn'tunreasonable, um, it would be
upheld.
Recently, the Supreme Courtrolled that back, overturned the
Chevron case and a case, arecent case called Loper Bright,
basically leveled a playingfield.
So it said whoever has the bestinterpretation, whether it's the
(29:05):
provider or the you knowregulated community, this is
beyond healthcare, this is allum agencies, but obviously has
implications in healthcare.
Um whoever has the bestinterpretation, whether it's the
agency or the regulated party,that's the interpretation that
should control.
There's a different level ofdeference for regulations called
our deference.
That's a whole nother topic.
(29:25):
I I could spend a long time onthat, but um, but I think it's
important for folks to know thatthat has been a very significant
change of four years worth ofprecedent that really is still
playing out.
I think Loper Bright was lessthan two years old, so we're
still beginning to see cases nowpercolate percolate up through
court.
Um that might be a goodtransition, kind of looking
(29:45):
ahead, um, maybe to ask whatmight be the final question for
folks, and I'll I'll give eachof you a choice whether you want
to tell us um something kind ofnew or interesting in your area,
in the particular area that youcovered, or um, you know, where
you think things are headed,what you think the future has in
store for part A or Part C orfraud and abuse, uh your choice.
(30:09):
But I'll start with you, Emily.
What uh Sure.
SPEAKER_02 (30:13):
So at the outset, I did know that uh typically when
folks think about Part A, theythink about facility services
and services that are in a brickand mortar location, uh,
particularly inpatient hospitalservices.
And what we have been seeingover the past few years, and I
anticipate will be rapidlyaccelerating uh in the next year
and beyond, is a movement ofservices outside of those
(30:36):
facilities into other locationsof care.
So we are seeing, for example,uh CMS's um efforts to shift
care from the inpatient settingto the outpatient setting with
the uh sunset of theinpatient-only list, for
example.
Those were services that couldonly be furnished as inpatient
hospital services, and now tothe extent that it is safe to do
(30:59):
so, could potentially befurnished in uh outpatient
settings, physician offices, orASCs, depending on the service.
Similarly, we are definitelyseeing an increase in movement
of services to patients in theirhomes.
So there is the hospital at homemodel that has been being tested
for several years now.
We're also seeing uh clientsstart to explore other types of
(31:21):
at-home services, um, whetherit's looking at can you do SNF
at home, uh, can you do somesort of home health plus that is
more than home health but lessthan inpatient hospital?
So I think we are going tocontinue to see really looking
at Part A as a moreservice-based uh coverage
(31:44):
category and less of alocation-based coverage
category.
SPEAKER_00 (31:49):
Before I move on to Elizabeth, Emily, can I follow
up?
Um, how much of that, if any, doyou think was driven by COVID
and the experience within thefederal healthcare system?
SPEAKER_02 (31:59):
It's really interesting.
I think that one thing to knowabout Medicare is it
significantly lags behind uh thehealthcare industry as a whole
in terms of uh both what itrecognizes as a method of care
delivery and what it will cover.
And during COVID, uh, because ofthe need to rapidly accelerate
uh the way in which serviceswere provided and covered,
(32:22):
Medicare actually started tolearn that perhaps they'd been a
little bit too conservative andperhaps there were some
opportunities to both increasepatient satisfaction and to
reduce cost to the Medicareprogram by covering services in
different locations in differentways.
I will say there are stilldefinitely some spaces where
Medicare continues tosignificantly lag behind the
(32:45):
technology and the coverage fromother payers.
But I would hope that as theyget that experience and get more
comfortable with some of theseinnovative models, that we'll
start to see them catch up alittle bit in terms of some of
those coverage opportunities.
SPEAKER_00 (32:59):
Elizabeth, how about you closing thoughts on Part C?
Either something new orinteresting, or maybe where you
think the Part C program isgoing.
SPEAKER_03 (33:07):
Yeah, I think one of the biggest issues that affects
the regulatory environment isjust the growth of the Medicare
population demographically, andthen the growth of Medicare Part
C.
And there was a little bit of adelay.
So, like it has grownsubstantially in the last 20
years from a really a niche,fairly regional managed care
(33:29):
option program to you know morethan half of people with
Medicare are in MedicareAdvantage.
And uh people have aged.
So if someone enrolled, youknow, 15 years ago in Medicare
Advantage, they probably weren'tin the hospital that year, but
maybe they, you know, nowthey're 80, maybe they are.
So we're starting to see thishuge um bolus of Medicare
(33:50):
Advantage beneficiaries inhospitals, and that's affecting
the provider communitytremendously.
Um, things like priorauthorization are becoming hot
button issues, not because theyhaven't always been there, but
because it was a much smallerproportion of um providers,
patient panels and um, you know,inpatient uh populations.
(34:13):
So we're just gonna be hearingthat all of the pain points,
prior authorization, riskadjustment, uh the marketing
issues that that swing back andforth.
Um we will be hearing more aboutthat um as the program continues
to grow and and as the umbeneficiaries in the um program
(34:34):
continue to age and and needmore intensive care.
SPEAKER_00 (34:38):
Elizabeth, I know you don't have a crystal ball,
but do you I do actually.
Okay, good.
Well then you can answer.
I don't really think that trendhas plateaued.
I mean you said it's over 50%.
That that's obviously a veryhigh percentage.
Do you think is it continued toaccelerate?
Where do you see that going?
SPEAKER_03 (34:55):
It the number of people is going to continue to
grow.
We saw a flattening off of thegrowth.
There was still growth lastyear, but it but there wasn't a
growth in the growth rate, ifthat makes sense.
So I think there is um, youknow, people are shopping
around, they're looking at theiroptions.
I think they understand um someof the, you know, not just the
(35:15):
upsides, but some of thearguable downsides of Medicare
Advantage, but it's not goingaway.
Um and so I don't think it'sever gonna, I I wouldn't expect
it to drop below 50%.
It might climb um less quicklythan some have predicted, but
it's gonna continue to be amajor factor in our Medicare
program.
SPEAKER_00 (35:36):
Susan, how about you?
Again, closing thoughts wherethings are going.
SPEAKER_04 (35:40):
Yeah, I I love listening to to each of my these
co-presenters here talk aboutthe part A pressures and and
movements and the part Cpressures and movements.
Anytime you see large uh shifts,right, and how patients are
managed in these variousprograms and how care progresses
through the system, those haveuh there are there are rules
promulgated on the front end umand they have real financial
(36:03):
impacts for providers on theback end, and there will be
errors and there will be ummisbehavior, right?
And so I I will be reallyinterested to watch the
evolution of the enforcementactivity, which which always
lags behind, right, the caredelivery changes to some extent.
But um but it will beinteresting to see, you know,
(36:23):
for example, Elizabeth, in thein the Part C space, some of the
pressures you mentioned on theprovider community delivering
care to a larger and largerpopulation of Part C patients.
Um we've started to see FalseClaims Act litigation against
providers for causing plans tosubmit false claims to CMS for
payment from CMS to the plans toreimburse those member lives.
(36:46):
And now the providers aregetting held liable under False
Claims Act for activity that um,well, I won't say it's new, but
but but but but it's it's it'sincreasing, right?
This this pressure.
Yeah, it'll be interesting towatch all of that and then to
watch it all in the context ofthe current regulatory
environment or deregulatoryenvironment, right?
(37:07):
The um the um distaste foragency regulations and and the
advent of Loper Bright and theum the reining in of deference,
judicial deference to agencyrulemaking, it will be um really
fascinating.
I think we're gonna see a a lotof continuing activity on that
(37:27):
front, right?
Pulse claims that's not goinganywhere.
Um and so so the cases are gonnacontinue to evolve, the
arguments are continue toevolve, the the judicial
positions are are gonna continueto develop um one way or
another.
Um and it'll it'll be really,really fascinating to see where
it all goes.
SPEAKER_00 (37:45):
Elizabeth, were you gonna add anything?
SPEAKER_03 (37:47):
No, I'm just nodding enthusiastically.
SPEAKER_00 (37:51):
Well, I'll say I already alluded to it um on the
in the appeals context, and anduh Susan mentioned it again.
I think in terms of looking tothe future, I think the Supreme
Court's recent Loper Brightdecision uh is gonna be some,
you know, I don't want tooversell it because really all
it does is level the playingfield, right?
The hospital, the regulatingregulated communities to less
(38:11):
approve that they have the bestinterpretation of the statute.
So it's by no means a slam dunk,but it really does remove that
very large thumb on the scale infavor of agency interpretations.
I also just one other comment inthe appeals context, which is I
think historically the appealswere focused on there are many
adjustments, right?
Medicare part A payment intheory is you know rather
(38:33):
simple.
There's a standardized amount,which is the cost between the
average patient, that'smultiplied by something called a
DRG diagnosis-related groupcode, which is every um illness
or injury has a DRG codeassociated with it to reflect
whether it's cheaper or or ummore expensive than the average
(38:53):
uh patient.
Um you multiply the two togetherand you get payment.
But then there's all sorts ofadjustments to that.
If hospitals that are teachinghospitals get a little bit more,
hospitals that treat adisproportionate share of
indigenous patients get a littlebit more, hospitals in higher
wage areas get a little bitmore.
Um and each of those adjustmentswere subject to appeals and
(39:14):
still are uh for decades now.
Um the GME, the DISH, the wageindex.
I think one thing that'sinteresting in the past, I don't
know, maybe a little over fiveyears, are challenges to the
calculation of that base rateitself.
So not just the adjustments, butthat that fundamental, that
standardized amount that Ireferenced.
Um and there's two big casesnow, and that was calculated
(39:36):
back in 1984, believe it or not.
So um I don't know if all of uswere were born then.
Um but but the courts have saidhospitals can challenge that,
not to get more payment back innineteen eighty four, but to fix
any errors going forward.
Um and so there's some big casesnow challenging again, not just
the adjustments, but really thefundamental building blocks.
(39:57):
And I think that's a good thing.
SPEAKER_03 (39:57):
And Dan, I was in I was in eight of your age.
I was in eighth grade in 1984.
SPEAKER_00 (40:02):
Well, I I was born in 1984 too.
I'm just gonna be a facultymember.
But anyway, with that, unlessthere's some closing thoughts
from folks, uh, I think we canwrap it up.
SPEAKER_03 (40:16):
I just had one thought when you were talking
about the deregulation,something that's gotten really
interesting in the part C space.
And I think in healthcare ingeneral, because you're doing
business with the federalgovernment, but then in part C,
it's it the regulations reallyimpact the relationship and the
balance of power between plansand providers and plans and drug
manufacturers.
And so it's really different.
(40:37):
Uh it's gonna be so, forexample, there's this request
for information out right now toum stakeholders about Medicare
Advantage, like how can wederegulate and make and
streamline this?
And it'll be really interestingto see how the provider
community potentially expresseslike, could you not?
(40:58):
You know, or maybe be reallycareful.
Um it's a very dynamic,complicated.
SPEAKER_04 (41:05):
It's a double-edged sword, right?
Because on the one hand, lessregulation equals more freedom,
maybe, but it's it's it alsoequals a lot of uncertainty.
Um and and uh these are issuesthat have been long settled for
a long time, and it's it's notnecessarily helpful, right?
To to the provider community orto anyone to eviscerate the the
entire encyclopedic body ofguidance.
SPEAKER_03 (41:28):
You want to be careful.
SPEAKER_04 (41:31):
I think that's a good point.
SPEAKER_00 (41:32):
Well, on that note, I think we'll wrap it up.
I hope folks enjoyed thepodcast.
As I alluded to at the outset,there's a whole uh 101 course.
This is we represent four of the10 modules.
There's others focused on partB, which obviously we didn't
talk about.
One of the modules was on thefuture of Medicare, talking
specifically about some of theseissues, about the demographic
trends.
Uh, but thank you.
(41:53):
Hope you enjoyed and take care.
SPEAKER_03 (41:54):
Thanks, everyone.
Thanks.
I appreciate it.
Hi.
Bye.
SPEAKER_01 (42:03):
If you enjoyed this episode, be sure to subscribe to
AHLA Speaking of Health Lawwherever you get your podcasts.
For more information about AHLAand the educational resources
available to the health lawcommunity.
Visit AmericanHealth Law.org andstay updated on breaking
healthcare industry news fromthe major media outlets with
AHLA's Health Law Daily Podcast,exclusively for AHLA
(42:25):
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, visitAmericanHealthlaw.org.
SPEAKER_00 (00:16):
Hello everyone.
I'm Dan Heddock.
I'm a partner in King andSwalding's healthcare practice
resident in Washington, D.C.
I'm uh hosting this podcastbecause I was faculty chair of
uh AHLA's Medicare 101 on demandcourse.
Um I'm very excited to be joinedby three of the faculty, three
other faculty members uh forthat call course.
(00:39):
If you haven't seen it yet, it'suh a 10-module um 101 course, as
as the name indicates, that youcan take at your own pace.
And I'll let each of the otherfaculty members introduce
themselves, but I'll just say byway of overview that we're gonna
be covering um the part A of theMedicare program, which covers
uh inpatient, uh hospitalinpatient care.
(01:02):
Uh part C, also known asMedicare Advantage.
Uh, we have the faculty memberwho did that module with us.
And then uh Medicare fraud andabuse, obviously an important
topic.
Um and then finally, my modulewe'll talk about just a little
bit.
I handled the uh appeals andarbitration um area, so areas of
controversy within Medicare.
But with that, I'll turn it overto my other faculty members.
(01:24):
Maybe Emily, could you uh kickus off, introduce yourself?
SPEAKER_02 (01:28):
Great, thank you, Dan.
I'm Emily Cook.
I'm a partner with McDermottWill and Schulte in our Los
Angeles office, and have beenworking for quite some time with
providers who receive paymentfrom Medicare, and I'm excited
to talk with uh all of you todayabout those coverage and uh
other rules.
SPEAKER_00 (01:47):
Thanks, Emily.
Elizabeth?
SPEAKER_03 (01:49):
Yeah, hi.
Um thanks, Dan.
I'm Elizabeth Lippincott.
I'm managing member of StrategicHealth Law, and I have been
doing um managed care work for25 years and founded this law
firm 20 years ago, and have beenum focusing primarily on
government managed care plans,particularly Medicare Advantage
and Part D for that time period.
SPEAKER_04 (02:11):
Susan?
Thanks, Dan.
I am Susan Banks.
I'm a partner at Holland Knightin the Denver office, and I
specialize in Medicarereimbursement and payment
issues.
And I had the opportunity todeliver the module at the med on
the 101 course on Medicare fraudand abuse topics.
So I'm looking forward todiscussing it with you all.
SPEAKER_00 (02:33):
Great.
Well, I'll ask my firstquestion, I think will be the
same for all of you.
I think for 101 it makes sense.
If each of you could give uskind of a nutshell of your
topic, obviously, you know,there's I know there's a lot to
be said on each of those topics,but really what a lawyer in this
space would need to know to beto be competent.
Um Emily, you handled the thePart A um module about Medicare
(02:56):
inpatient.
Maybe I'll start with you.
SPEAKER_02 (02:58):
Sure.
Medicare Part A generally isconsidered to be the component
of the Medicare program thatcovers what are often referred
to as facility services.
So primarily when you think ofPart A, most people are going to
think of general acute careinpatient hospital services.
Although it is uh quite a bitmore broad, Medicare Part A also
(03:19):
covers home health, hospice,end-stage renal disease, and
actually quite a few otherservices.
So while the general uh approachto Part A is that it is covering
hospital inpatient services, itis uh quite a bit more broad
than that.
SPEAKER_00 (03:35):
Great.
Thank you, Emily.
Um Elizabeth, maybe can you tellus about Part C?
What is what do folks need toknow to be competent about
Medicare Part C?
SPEAKER_03 (03:44):
Yeah, I think the most important thing in Medicare
Part C is just to know what theuniverse of regulations and
guidance is and to be aware ofthe primacy of subregulatory
guidance and um to know howimportant it is.
Um and and it we use the wordguidance, but because for the
(04:04):
Medicare Advantageorganizations, they are required
in their contracts to complywith guidance.
Guidance is really a misnomer.
They're requirements for theplan and for their that's flowed
down to their vendors andproviders.
So really knowing how to accessthe voluminous manuals as
updated memos, um, QAs,reporting guidance, just
(04:29):
thousands of pages ofinstructions is probably the
most important thing.
So at least you know where tolook and know that whatever
random question you might have,there's probably an answer
somewhere or somehow it'saddressed.
There's a decent chance.
It's just so highly regulated.
Um, it's it's pretty intense interms of the requirements and
(04:54):
how granular they are.
SPEAKER_00 (04:56):
Right.
Susan, what what would youranswer be for fraud and abuse?
SPEAKER_04 (05:00):
You know, I Medicare fraud and abuse or federal
healthcare program fraud andabuse broadly.
Um, a lot of it is is uh basedon it, it's it's grounded in a
lot of the same types ofmaterials that Elizabeth was
just referencing, right?
These are the broad federal andstate law analogs, statutory
regulatory frameworks thatpolice uh improper business
(05:22):
contact conduct in thehealthcare arena, right?
So everything from um uhover-billing, uh improper
billing, billing the wrongservices, uh, to providing too
many services, medicallyunnecessary services, or uh
worthless services, right?
When when services fall below acertain threshold so that
(05:44):
they're not even good andvaluable services.
Um so the fraud and abuse lawsare um broad.
The penalties associated withviolating them are um can be
truly enormous.
Everything from um you knowoverpayment penalties and and
damages associated with billingincorrectly to um potential
(06:10):
stays in prison for for moresignificant conduct that
violates the laws.
So, you know, to Elizabeth'spoint, in such a highly
regulated industry, I thinkwhere we see things go wrong,
even even the most well-meaningproviders and suppliers get it
wrong sometimes.
And and the folks who are perpotentially newer, newer
entrants into the market, who'vetransitioned from other business
(06:31):
lines maybe into the healthcarespace, and there's there's a bit
of a learning curve.
There's there's a lot to beaware of in in the healthcare
arena that uh may not beintuitive always.
SPEAKER_00 (06:41):
Right.
Well, I'll answer my ownquestion for the appeals and
arbitration area.
I think um obviously there's alot that could be said, um, as I
alluded to, but I think one ofthe things, one of the
fundamental aspects to be awareof is that each of the different
parts of Medicare, and we kindof alluded to it, maybe we
should have said a little bitmore about it, but part A is
(07:01):
only says primarily inpatient,part B is more outpatient
physician services, part C isthe managed care with the
private companies, part D, whichwe won't be talking too much
about today, but focuses onprescription drugs.
And each of those areas havetheir own appeal mechanism.
Um part A generally goes throughif a hospital has a complaint
(07:22):
about how Medicare isreimbursing for inpatient
services, those usually wouldrun through the provider
reimbursement review board.
That's where I spend most of mytime.
Um Part C, for example, is anentirely different animal.
Usually it's governed bycontractual language and usually
more arbitration, as uhElizabeth alluded to.
Um Part D, another unique uhanimal.
(07:43):
Actually, there's been a recentappeal mechanism for when
there's disputes between drugmanufacturers and uh uh
typically hospitals who receivediscounts, the 340B program.
Um so I think maybe onefundamental takeaway for folks
there is that there's adifferent, then there's also the
um DAB and ALJ appeal processfor individual services.
(08:08):
So I think at the highest level,folks should be aware that there
are different uh appealmechanisms, uh sometimes very
different, for each of thoseprograms.
If we have a little bit timelater, I might talk a little bit
more about again part A appeals,which is where I spend my time.
But Emily, I did want to go backto you.
I know you alluded to alreadythat, you know, as we said a
couple of times now, part A isprimarily inpatient care, but
(08:32):
encompasses other stuff likehospice, et cetera.
Who determines what is and isnot covered by Part A, by
Medicare Part A?
SPEAKER_02 (08:41):
Sure.
So there is a hierarchy of uhwho determines what is covered.
And I think uh building on whatuh Elizabeth was mentioning
about guidance, um, in the PartA space, uh, we always start
with the statute.
Uh so we will first look to seewhat Congress has said about
what is covered by Medicare andwhat isn't.
(09:02):
Uh they don't say a lot aboutit.
Most of the information thatcomes from the statute is at a
very high level and does notprovide the necessary
granularity to understand in anyparticular instance what is or
is not covered.
And then we look at theregulations.
And while the regulations, asyou would expect, are somewhat
(09:23):
more detailed, particularly inthe Medicare Part A space.
They provide very little insightto whether a particular service,
and typically the part A we'retalking about a stay rather than
an individual service.
So a particular patient's day ata facility is covered.
So then we look to the guidance,uh, and we may get some more
information in the guidance inthe Medicare space across all
(09:44):
parts of Medicare.
The guidance is something thatwe use very, very frequently and
more frequently than thestatutes or the regulations.
Um, and in part A, we also seequite a lot of information
coming from the Medicareadministrative contractors.
Those are companies that havecontracted with the Centers for
(10:05):
Medicare and Medicaid Servicesto actually administer the
Medicare program.
And they themselves issueguidance that provides
information about coverage,particularly what are known as
national coverage determinationsand local coverage
determinations.
So in any given instance, whenwe are trying to determine
(10:25):
whether a particular part, aservice or stay is covered,
there is uh quite a bit ofmaterial that needs to be
reviewed, again, starting withthe statute, ending with uh the
Medicare administrativecontractor guidance.
SPEAKER_00 (10:40):
Great.
Elizabeth, I'm curious if youhave thoughts.
Um, I mean based on what Emilysaid, and I think there's often
a lot of confusion about what'ssimilar with part C compared to
part A, what's different, howmuch of that that Emily
described with the statuteregulations policy, does that
apply at all under Part C?
Um, how is Part C different fromPart A?
How is it the same?
SPEAKER_03 (11:02):
It's very similar in terms of the you know tiering of
statutory um authorityregulations.
And I would add, um it's it'sreally important in reviewing
the regulations that you sort ofdo the regulatory history and
look back at the we've got a uman index of it's incredible how
many times these have beenupdated.
(11:22):
And there's a lot of goodcommentary in there that I think
of as guidance or kind ofregulatory history, and then um
the manuals, the part C manuals,and then another wrinkle that
does tie back to what Emily wastalking about with the um
national and local coveragedeterminations in original
Medicare.
So for Medicare Advantage plans,they are um underwritten and
(11:45):
administered by privateinsurance companies.
Um, however, the floor forbenefits is what is covered by
um original Medicare.
So for inpatient, it's part A.
And CMS has clarified in thelast few years, this has always
been the case, but they'vethey've sort of added to their
interpretation that coveragerules from Part A have to be
(12:08):
adhered to by Part C MedicareAdvantage plans.
Payment rules generally speakingdo not.
So the payment for in-networkproviders is um determined in
the contract between the Part Cplan and the provider, in this
case, the hospital.
However, um according to CMS,more and more things that we
(12:31):
historically thought of aspayment rules, not necessarily
applicable, are now beingtreated as coverage rules if
they um determine someone'saccess to um coverage in an
inpatient setting.
So there is overlap, and I wouldsay over the last couple of
years, that overlap has grownbecause of that um emphasis from
(12:52):
the regulators.
SPEAKER_00 (12:54):
Right.
And Susan, I imagine there aretimes where folks don't follow
all the statutes, regulations,and policies that uh Emily and
Elizabeth alluded to.
Uh is that where the FalseClaims Act uh kind of kicks in?
SPEAKER_04 (13:11):
Yes, often, right?
The False Claims Act remains oneof the biggest enforcement tools
and most prevalent enforcementtools that are used by um by
regulators in this space.
It's um it's it's I was gonnasay unique.
I don't know that it's unique,but but it's an extraordinarily
broad statute, right, with awide reach in terms of conduct.
(13:33):
And it's been um deployed withgreat uh success from the
government's perspective, right,in in the healthcare regulatory
space because of the nexus withclaims submitted to the federal
government.
So so what the False Claims Actprohibits, just very very
broadly and generally, right, itpolices the submission of
(13:55):
improper false claims to thefederal government for payment.
And so in the healthcare conductcontext, sorry, a claim is is, I
think it's it's definedintuitively mostly, right?
For for most purposes, it's ait's a bill for services, an
invoice for services, a claimfor payment, you you submit a
document that um initiates apayment by the government.
(14:17):
And what the False Claims Actprohibits is the knowing
submission of false claims.
So if there's material,materially false information
either on the face of the claim,you billed for a knee
replacement and should havebilled for a hip replacement, um
materially false and faciallyincorrect information on the
(14:38):
claim.
Or if by merely submitting thatclaim you're certifying, you're
making a representation toMedicare in this case that you
have followed all the paymentrules necessary to qualify for
that payment, that's that'scalled an implied certification,
right, of compliance.
If you've submitted the claimand you know it's incorrect,
which means you have actualknowledge that it's incorrect,
(15:01):
or you are um acting indeliberate ignorance of whether
or not it's incorrect, um, orum, gosh, I'm forgetting the
third one.
Y'all help me out.
Actually, actual knowledge,deliberate ignorance, or
reckless disregard.
SPEAKER_03 (15:17):
Reckless disregard.
SPEAKER_04 (15:18):
Reckless disregard, um, which is actually probably
the one of the most common onesthat comes up all the time.
So that's funny that it shouldslip my mind.
But if you have you are notpaying attention to, right,
whether in the extent to whichthat uh certification of
compliance, the information onthat claim is correct or
incorrect, you've submitted afalse claim.
(15:39):
And so what false claims actlitigation comes down to always
is the quality of the guidance,right?
Whether it's the claim is isprohibited on the face of the
statute, on the face of aregulation that was duly
promulgated by the agency thatthat prohibits the claim at
(16:00):
issue, or states a complianceobligation that you know you
didn't meet and yet yousubmitted the claim anyway, um,
or or even down in thesubregulatory context, right?
So to the the extent to whichand it's fascinating to dig to
dig deeper down in there, butthe extent to which there was
other guidance that's that's notduly promulgated in a
(16:21):
regulation, but it either isdeserving of deference or or it
caused, gave you reason to knowthat your claim would was
incorrect in one way or another.
Um violation of those guidelinescan also form the basis of a
false claim.
It's it's super fact specific.
It always is.
Um I'll I'll pause there.
(16:43):
There's more I could say onthat, but but I want to let
other folks jump in becausethere's some really neat
differences between the part Aand the Part C context.
SPEAKER_03 (16:49):
You made a really good point, Susan, in your
comments earlier about howchallenging it can be to enter
this area of industry from otherindustries because it's so
regulated and you're dealingwith federal dollars and federal
programs.
And I I'll go out on a limb andsay the biggest culture shock is
for people that have um grown upin the tech industry, which is
(17:13):
one of the least, it's notcompletely unregulated, but it's
one of the least regulated areasof our economy outside that, you
know, when you're not in thehealth context.
Coming from tech to health, um,and I'm not saying that's bad or
good, it has pros and cons, andit's probably why we've had such
incredible innovation here, butcoming from, you know, a tech
environment into healthcare,especially in the Medicare
(17:34):
space, you've got what you'vejust described with the False
Claims Act, and also what youtouched on, which is the
interaction with theanti-kickback statute, that if
you're submitting claims, you'reaffirming that you don't have
any kickback statute violationsin place.
It's a criminal law and it's nottotally intuitive.
(17:55):
And there are things that mightnot feel morally wrong and might
be normal business practices inother industries in terms of
exchange of value that can getyou sent to jail in this space.
So it really is a very differentuniverse.
And um, these concepts are soimportant for people to
understand um when they're doingbusiness, you know, before they
(18:17):
even have a before they evenknow they have a question.
SPEAKER_02 (18:20):
I think that comes up a lot for me with folks who
have uh ideas about innovativecare delivery models.
And as you noted, there arequite a lot of uh, particularly
at this point in time, emerginginnovative care delivery models,
but there are also scenarios inwhich uh someone will come up
with what they believe to be agreat idea about how to deliver
(18:43):
health care that no one has comeup with before.
And uh I will say that uh moreoften than not, it is not that
someone has not come up with itbefore, it's that it's illegal.
And communicating that to folkswho do not regularly work in
this space can be verychallenging.
SPEAKER_04 (19:02):
It's really true.
And I think the kickback statutethat you mentioned, Elizabeth,
we haven't really gotten into itand we sure can in greater
depth.
But that's one of the areas thatI think is most fascinating
because some of the activity,right, this notion of
incentivizing business, right?
It just makes good businesssense.
You come from any otherindustry, commercial industry in
the US.
Um, uh, and it of course I'lloffer you a discount if you'll
(19:26):
buy more of my product, right?
But as soon as you throw infederal healthcare program
dollars into the mix, and whatthat incentive is, what that
discount means is that you'regoing to order more of my item
or service that's reimbursableby a federal health care
program.
Well, now you're incentivizingit now, they call it a kickback,
right?
Because what you'reincentivizing are referrals, and
(19:48):
and the one who's gonna pay forit is the federal government.
And so there's a law to toprohibit what otherwise would
just make good business sense.
And I think, yeah.
SPEAKER_03 (19:57):
I have an anecdote.
I was in a business coachingprogram for a while.
With all people from alldifferent kinds of businesses.
And um, this great guy was adentist.
He had a very, very high-end umprivate paid dental practice.
And something that he did is hewould offer, he would have an
auto-detailer come and um detailhis patient's cars when they
(20:18):
came for their appointments.
And I was like, you don't takeany federal money, do you?
He's like, no, no.
I'm like, never, ever, everenroll with any state or federal
friend.
Just don't.
It's you're not cut out for it,you know.
But it's that kind of thing.
SPEAKER_00 (20:36):
Elizabeth, you have to tell me that dentist's name.
I wouldn't mind having mydetailed getting my teeth.
Um well, you you guys alluded toit a little bit already, but
maybe, maybe Susan, this ismaybe most in your wheelhouse.
Can you talk to us a little bitmore about the penalties?
I know Elizabeth alluded tojail.
Obviously, that's you knowunusual and probably like the
worst, but what are thepenalties associated with
(20:56):
violations of um either theanti-kickback or the um false
claims act?
Obviously, they're different.
Yeah, maybe just give us a senseof what the what the stakes are.
SPEAKER_04 (21:05):
Absolutely.
Well, I'll I'll start with thethe false claims act penalties.
Um those penalties are based onand they're calculated on the
basis of the amount of re theamount of remuneration that you
received, the amount of paymentyou received in exchange for the
false claim, right?
So, so um baseline damages areare this single damages, right?
(21:27):
Would be the amount of moneythat you that you got paid for
all the claims that were foundto have been false in violation
of the statute.
False claims that penalties canbe up to treble damages, so
three times that amount, andwhich which sounds like a lot,
and it is a lot.
But then also uh you can getcharged um penalties on top of
the trouble damages, and thepenalties are per claim damages,
(21:49):
which means for every claim thatis submitted, um you can get an
additional penalty amountbetween, I think it's around
15,000 minimum to 30,000, closeto 30,000 maximum at the moment.
And I don't have the exactnumbers in front of me, but it's
significant.
I mean, so imagine, imagine amedically unnecessary UTI
(22:11):
testing um issue, and you youend up getting uh certainly the
trouble damages amount that theamount you got paid for these
UTI uh urine tests that weremore than more than should have
been billed, right?
Maybe you were testing too manyservices or testing too many
patients.
Um, so you've got troubledamages, but then every single
(22:32):
individual claim for aurinalysis will then generate
either the minimum,$15,000 perup to about$30,000 per.
And those per claim penalties umreally balloon very quickly, and
they can they can rapidlyeclipse the trouble damages
amount.
Um, and some of these some ofthese settlements and and
(22:52):
assessed penalties are areastronomical.
SPEAKER_00 (22:55):
Um so that's Elizabeth, are there analogs in
the Part C context?
I mean, if if or because it'sprivate contracts, is it
different?
SPEAKER_03 (23:04):
Yes.
A lot of the um well, the mosthigh risk area in Medicare
Advantage is risk adjustment,which we explain the
fundamentals of in the in thecourse, the Part C module.
But um essentially health memberspecific health information
diagnosis codes are submitted bythe plans.
(23:25):
They originate with providersgenerally.
They're submitted by the plansto the federal government, and
um for certain um high costdiagnoses, you receive more
money every month from thefederal government.
Those are subject to audit bythe government, as well as um
they are a lucrative form of umwhistleblower litigation claims,
(23:47):
um, and they're uh hotlyrecruited by um whistleblower
plaintiffs lawyers, and we haveseen settlements in the tens of
millions of dollars and evenbeyond.
Um, so uh those can be the thedefendants in those can be both
the plans that are um submittingthose claims directly and also
(24:10):
their vendors and theirhealthcare providers that are
submitting data and diagnosesthat are used to determine
federal payment.
Um, so it's a risk area forproviders as well, especially if
they're taking risk undervalue-based contracts with
Medicare Advantage plans.
They can be defendants in thoselawsuits as well.
(24:31):
And and it's really um thingthat makes it um so risky is the
um, I don't think this is theonly motive for for
whistleblowers, frankly, butthere is a very strong profit
motive where they can take homeuh 15 to 30 percent of the
settlement or the damages.
So um strong incentive for themto bring these lawsuits, the
(24:54):
Department of Justice can umjoin them or not, or intervene
or not.
Um, but yeah, it to answer yourquestion, yes, definitely
there's risk.
SPEAKER_00 (25:03):
And I will say Oh yeah, please.
I was gonna ask you so go ahead.
SPEAKER_02 (25:08):
Sure.
So I will say that um asElizabeth alluded to, there can
be whistleblower actions in theMedicare space.
And that is another good sourceof information about the types
of activities that could get uha provider, if not in trouble
with the government, uh, subjectto a significant amount of
(25:29):
administrative and financialburden.
One of the very interestingaspects about the Medicare
program uh and its relationshipto the Federal False Claims Act
and the uh key TAM orwhistleblower provisions is that
a whistleblower doesn'tnecessarily need to actually be
(25:50):
correct in their allegationsthat a provider has violated the
law and submitted false claims.
Uh, that can still create asignificant amount of burden for
providers.
Typically, um, whistleblowerswill uh be motivated uh by the
potential financial recovery inthose cases and will only bring
(26:12):
cases where they think that theyare going to ultimately prevail
and uh obtain uh the at leastcost of their litigation and
some additional uh money on topof that.
But I would say I think all ofus probably deal with scenarios
where there are incrediblyspecious allegations or that the
underlying uh violation is notan actual violation, and it
(26:35):
doesn't really matter in termsof having to defend those cases.
It can cost you as much todefend a case that is completely
unwarranted as it does to defenda case that actually has some
potential uh violations in theallegations.
SPEAKER_00 (26:53):
I'll I'll take just another moment to talk about the
um kind of similar ideas in theappeals context, which I think
is different.
A lot of what we've beendiscussing is kind of defensive.
Um usually providers are um onthe defensive end of being
accused of uh violating someprovision.
On the appeals side, it's almostthe reverse of that, where um
(27:16):
sometimes providers think thatthe government itself hasn't
reimbursed them the way Congressor the way the statute says they
should be reimbursed, or the waythe agency's own regulation um
says they should be uhreimbursed, for example.
Um and there is this mechanismfor hospitals or other providers
to to appeal thosedeterminations and challenge the
(27:37):
agency's uh reimbursementdecisions.
Um and I'm focusing again, Isaid at the outset, like each of
the different parts of theMedicare have different appeal
mechanisms.
This is more on the part Ainpatient side.
Um but in those cases, if ahospital thinks that CMS is not
reimbursing as the statute ofregulation um requires, they can
(27:59):
bring these affirmative appealsthat start off at the
administrative level, eventuallygoes to the federal court, some
even to the Supreme Court.
Um I'll just mention one.
This is my area, so it's it's itmight be nerdy, but but I like
it.
Um so I find it fascinating.
But I'll focus just on oneaspect uh because I think it is
important, an important seachange, um, which is this recent
(28:22):
Supreme Court decision,historically for the past 40
years up until two years ago.
Um, any type of challenge likethat, the agency got a very
significant deference, you know,in its its interpretation of the
statute or or its ownregulation.
Um particularly the questions ofstatutory interpretation.
The Supreme Court in a casecalled Chevron had said, unless
(28:44):
the agency's interpretation wasactively unreasonable, it didn't
have to be the best.
As long as it wasn'tunreasonable, um, it would be
upheld.
Recently, the Supreme Courtrolled that back, overturned the
Chevron case and a case, arecent case called Loper Bright,
basically leveled a playingfield.
So it said whoever has the bestinterpretation, whether it's the
(29:05):
provider or the you knowregulated community, this is
beyond healthcare, this is allum agencies, but obviously has
implications in healthcare.
Um whoever has the bestinterpretation, whether it's the
agency or the regulated party,that's the interpretation that
should control.
There's a different level ofdeference for regulations called
our deference.
That's a whole nother topic.
(29:25):
I I could spend a long time onthat, but um, but I think it's
important for folks to know thatthat has been a very significant
change of four years worth ofprecedent that really is still
playing out.
I think Loper Bright was lessthan two years old, so we're
still beginning to see cases nowpercolate percolate up through
court.
Um that might be a goodtransition, kind of looking
(29:45):
ahead, um, maybe to ask whatmight be the final question for
folks, and I'll I'll give eachof you a choice whether you want
to tell us um something kind ofnew or interesting in your area,
in the particular area that youcovered, or um, you know, where
you think things are headed,what you think the future has in
store for part A or Part C orfraud and abuse, uh your choice.
(30:09):
But I'll start with you, Emily.
What uh Sure.
SPEAKER_02 (30:13):
So at the outset, I did know that uh typically when
folks think about Part A, theythink about facility services
and services that are in a brickand mortar location, uh,
particularly inpatient hospitalservices.
And what we have been seeingover the past few years, and I
anticipate will be rapidlyaccelerating uh in the next year
and beyond, is a movement ofservices outside of those
(30:36):
facilities into other locationsof care.
So we are seeing, for example,uh CMS's um efforts to shift
care from the inpatient settingto the outpatient setting with
the uh sunset of theinpatient-only list, for
example.
Those were services that couldonly be furnished as inpatient
hospital services, and now tothe extent that it is safe to do
(30:59):
so, could potentially befurnished in uh outpatient
settings, physician offices, orASCs, depending on the service.
Similarly, we are definitelyseeing an increase in movement
of services to patients in theirhomes.
So there is the hospital at homemodel that has been being tested
for several years now.
We're also seeing uh clientsstart to explore other types of
(31:21):
at-home services, um, whetherit's looking at can you do SNF
at home, uh, can you do somesort of home health plus that is
more than home health but lessthan inpatient hospital?
So I think we are going tocontinue to see really looking
at Part A as a moreservice-based uh coverage
(31:44):
category and less of alocation-based coverage
category.
SPEAKER_00 (31:49):
Before I move on to Elizabeth, Emily, can I follow
up?
Um, how much of that, if any, doyou think was driven by COVID
and the experience within thefederal healthcare system?
SPEAKER_02 (31:59):
It's really interesting.
I think that one thing to knowabout Medicare is it
significantly lags behind uh thehealthcare industry as a whole
in terms of uh both what itrecognizes as a method of care
delivery and what it will cover.
And during COVID, uh, because ofthe need to rapidly accelerate
uh the way in which serviceswere provided and covered,
(32:22):
Medicare actually started tolearn that perhaps they'd been a
little bit too conservative andperhaps there were some
opportunities to both increasepatient satisfaction and to
reduce cost to the Medicareprogram by covering services in
different locations in differentways.
I will say there are stilldefinitely some spaces where
Medicare continues tosignificantly lag behind the
(32:45):
technology and the coverage fromother payers.
But I would hope that as theyget that experience and get more
comfortable with some of theseinnovative models, that we'll
start to see them catch up alittle bit in terms of some of
those coverage opportunities.
SPEAKER_00 (32:59):
Elizabeth, how about you closing thoughts on Part C?
Either something new orinteresting, or maybe where you
think the Part C program isgoing.
SPEAKER_03 (33:07):
Yeah, I think one of the biggest issues that affects
the regulatory environment isjust the growth of the Medicare
population demographically, andthen the growth of Medicare Part
C.
And there was a little bit of adelay.
So, like it has grownsubstantially in the last 20
years from a really a niche,fairly regional managed care
(33:29):
option program to you know morethan half of people with
Medicare are in MedicareAdvantage.
And uh people have aged.
So if someone enrolled, youknow, 15 years ago in Medicare
Advantage, they probably weren'tin the hospital that year, but
maybe they, you know, nowthey're 80, maybe they are.
So we're starting to see thishuge um bolus of Medicare
(33:50):
Advantage beneficiaries inhospitals, and that's affecting
the provider communitytremendously.
Um, things like priorauthorization are becoming hot
button issues, not because theyhaven't always been there, but
because it was a much smallerproportion of um providers,
patient panels and um, you know,inpatient uh populations.
(34:13):
So we're just gonna be hearingthat all of the pain points,
prior authorization, riskadjustment, uh the marketing
issues that that swing back andforth.
Um we will be hearing more aboutthat um as the program continues
to grow and and as the umbeneficiaries in the um program
(34:34):
continue to age and and needmore intensive care.
SPEAKER_00 (34:38):
Elizabeth, I know you don't have a crystal ball,
but do you I do actually.
Okay, good.
Well then you can answer.
I don't really think that trendhas plateaued.
I mean you said it's over 50%.
That that's obviously a veryhigh percentage.
Do you think is it continued toaccelerate?
Where do you see that going?
SPEAKER_03 (34:55):
It the number of people is going to continue to
grow.
We saw a flattening off of thegrowth.
There was still growth lastyear, but it but there wasn't a
growth in the growth rate, ifthat makes sense.
So I think there is um, youknow, people are shopping
around, they're looking at theiroptions.
I think they understand um someof the, you know, not just the
(35:15):
upsides, but some of thearguable downsides of Medicare
Advantage, but it's not goingaway.
Um and so I don't think it'sever gonna, I I wouldn't expect
it to drop below 50%.
It might climb um less quicklythan some have predicted, but
it's gonna continue to be amajor factor in our Medicare
program.
SPEAKER_00 (35:36):
Susan, how about you?
Again, closing thoughts wherethings are going.
SPEAKER_04 (35:40):
Yeah, I I love listening to to each of my these
co-presenters here talk aboutthe part A pressures and and
movements and the part Cpressures and movements.
Anytime you see large uh shifts,right, and how patients are
managed in these variousprograms and how care progresses
through the system, those haveuh there are there are rules
promulgated on the front end umand they have real financial
(36:03):
impacts for providers on theback end, and there will be
errors and there will be ummisbehavior, right?
And so I I will be reallyinterested to watch the
evolution of the enforcementactivity, which which always
lags behind, right, the caredelivery changes to some extent.
But um but it will beinteresting to see, you know,
(36:23):
for example, Elizabeth, in thein the Part C space, some of the
pressures you mentioned on theprovider community delivering
care to a larger and largerpopulation of Part C patients.
Um we've started to see FalseClaims Act litigation against
providers for causing plans tosubmit false claims to CMS for
payment from CMS to the plans toreimburse those member lives.
(36:46):
And now the providers aregetting held liable under False
Claims Act for activity that um,well, I won't say it's new, but
but but but but it's it's it'sincreasing, right?
This this pressure.
Yeah, it'll be interesting towatch all of that and then to
watch it all in the context ofthe current regulatory
environment or deregulatoryenvironment, right?
(37:07):
The um the um distaste foragency regulations and and the
advent of Loper Bright and theum the reining in of deference,
judicial deference to agencyrulemaking, it will be um really
fascinating.
I think we're gonna see a a lotof continuing activity on that
(37:27):
front, right?
Pulse claims that's not goinganywhere.
Um and so so the cases are gonnacontinue to evolve, the
arguments are continue toevolve, the the judicial
positions are are gonna continueto develop um one way or
another.
Um and it'll it'll be really,really fascinating to see where
it all goes.
SPEAKER_00 (37:45):
Elizabeth, were you gonna add anything?
SPEAKER_03 (37:47):
No, I'm just nodding enthusiastically.
SPEAKER_00 (37:51):
Well, I'll say I already alluded to it um on the
in the appeals context, and anduh Susan mentioned it again.
I think in terms of looking tothe future, I think the Supreme
Court's recent Loper Brightdecision uh is gonna be some,
you know, I don't want tooversell it because really all
it does is level the playingfield, right?
The hospital, the regulatingregulated communities to less
(38:11):
approve that they have the bestinterpretation of the statute.
So it's by no means a slam dunk,but it really does remove that
very large thumb on the scale infavor of agency interpretations.
I also just one other comment inthe appeals context, which is I
think historically the appealswere focused on there are many
adjustments, right?
Medicare part A payment intheory is you know rather
(38:33):
simple.
There's a standardized amount,which is the cost between the
average patient, that'smultiplied by something called a
DRG diagnosis-related groupcode, which is every um illness
or injury has a DRG codeassociated with it to reflect
whether it's cheaper or or ummore expensive than the average
(38:53):
uh patient.
Um you multiply the two togetherand you get payment.
But then there's all sorts ofadjustments to that.
If hospitals that are teachinghospitals get a little bit more,
hospitals that treat adisproportionate share of
indigenous patients get a littlebit more, hospitals in higher
wage areas get a little bitmore.
Um and each of those adjustmentswere subject to appeals and
(39:14):
still are uh for decades now.
Um the GME, the DISH, the wageindex.
I think one thing that'sinteresting in the past, I don't
know, maybe a little over fiveyears, are challenges to the
calculation of that base rateitself.
So not just the adjustments, butthat that fundamental, that
standardized amount that Ireferenced.
Um and there's two big casesnow, and that was calculated
(39:36):
back in 1984, believe it or not.
So um I don't know if all of uswere were born then.
Um but but the courts have saidhospitals can challenge that,
not to get more payment back innineteen eighty four, but to fix
any errors going forward.
Um and so there's some big casesnow challenging again, not just
the adjustments, but really thefundamental building blocks.
(39:57):
And I think that's a good thing.
SPEAKER_03 (39:57):
And Dan, I was in I was in eight of your age.
I was in eighth grade in 1984.
SPEAKER_00 (40:02):
Well, I I was born in 1984 too.
I'm just gonna be a facultymember.
But anyway, with that, unlessthere's some closing thoughts
from folks, uh, I think we canwrap it up.
SPEAKER_03 (40:16):
I just had one thought when you were talking
about the deregulation,something that's gotten really
interesting in the part C space.
And I think in healthcare ingeneral, because you're doing
business with the federalgovernment, but then in part C,
it's it the regulations reallyimpact the relationship and the
balance of power between plansand providers and plans and drug
manufacturers.
And so it's really different.
(40:37):
Uh it's gonna be so, forexample, there's this request
for information out right now toum stakeholders about Medicare
Advantage, like how can wederegulate and make and
streamline this?
And it'll be really interestingto see how the provider
community potentially expresseslike, could you not?
(40:58):
You know, or maybe be reallycareful.
Um it's a very dynamic,complicated.
SPEAKER_04 (41:05):
It's a double-edged sword, right?
Because on the one hand, lessregulation equals more freedom,
maybe, but it's it's it alsoequals a lot of uncertainty.
Um and and uh these are issuesthat have been long settled for
a long time, and it's it's notnecessarily helpful, right?
To to the provider community orto anyone to eviscerate the the
entire encyclopedic body ofguidance.
SPEAKER_03 (41:28):
You want to be careful.
SPEAKER_04 (41:31):
I think that's a good point.
SPEAKER_00 (41:32):
Well, on that note, I think we'll wrap it up.
I hope folks enjoyed thepodcast.
As I alluded to at the outset,there's a whole uh 101 course.
This is we represent four of the10 modules.
There's others focused on partB, which obviously we didn't
talk about.
One of the modules was on thefuture of Medicare, talking
specifically about some of theseissues, about the demographic
trends.
Uh, but thank you.
(41:53):
Hope you enjoyed and take care.
SPEAKER_03 (41:54):
Thanks, everyone.
Thanks.
I appreciate it.
Hi.
Bye.
SPEAKER_01 (42:03):
If you enjoyed this episode, be sure to subscribe to
AHLA Speaking of Health Lawwherever you get your podcasts.
For more information about AHLAand the educational resources
available to the health lawcommunity.
Visit AmericanHealth Law.org andstay updated on breaking
healthcare industry news fromthe major media outlets with
AHLA's Health Law Daily Podcast,exclusively for AHLA
(42:25):
comprehensive members.
To subscribe and add thisprivate podcast feed to your
podcast app, go toamericanhealthlaw.org slash
daily podcast.
Popular Podcasts
Two Guys, Five Rings: Matt, Bowen & The Olympics
Two Guys (Bowen Yang and Matt Rogers). Five Rings (you know, from the Olympics logo). One essential podcast for the 2026 Milan-Cortina Winter Olympics. Bowen Yang (SNL, Wicked) and Matt Rogers (Palm Royale, No Good Deed) of Las Culturistas are back for a second season of Two Guys, Five Rings, a collaboration with NBC Sports and iHeartRadio. In this 15-episode event, Bowen and Matt discuss the top storylines, obsess over Italian culture, and find out what really goes on in the Olympic Village.
iHeartOlympics: The Latest
Listen to the latest news from the 2026 Winter Olympics.
Milan Cortina Winter Olympics
The 2026 Winter Olympics in Milan Cortina are here and have everyone talking. iHeartPodcasts is buzzing with content in honor of the XXV Winter Olympics We’re bringing you episodes from a variety of iHeartPodcast shows to help you keep up with the action. Follow Milan Cortina Winter Olympics so you don’t miss any coverage of the 2026 Winter Olympics, and if you like what you hear, be sure to follow each Podcast in the feed for more great content from iHeartPodcasts.