Bass, Berry & Sims attorney Lindsey Fetzer was interviewed for an article in AIS Health – Radar on Medicare Advantage discussing enforcement trends related to Medicare Risk Adjustment (MRA) and sales and marketing practices, including the use of third-party agents and brokers in the Medicare Advantage (MA) plan enrollment process.
When asked whether there any other new type of conduct arising in the managed care space from False Claims Act settlements or ongoing lawsuits, Lindsey noted a focus on sales and marketing practices by the Department of Justice, Centers for Medicare & Medicaid Services, and other regulators, commenting that the conduct and landscape “hasn’t changed, but it has not been scrutinized like this in such a focused way.” Regarding MRA enforcement, Lindsey said, “we are seeing similar fact patterns in terms of the underlying idea of adding unsupported risk adjusting codes through things like one-way chart reviews or health risk assessments, but we’re also seeing this increased focus and scrutiny on the technology tools that are used to identify the potential conditions. So, I would say just a new flavor to what the data analytics look like and how large language models and [natural language processing] can be used and create risk.”
In response to a question about advice she would give, Lindsey said, “I would advise plans and other value-based care entities to approach oversight and compliance in a way that is maturing commensurate with how providers and plans are [operationally] maturing …. and oversight should be thinking through more than just risk adjustment … and instead think through the life cycle of where risk could be.”
The full article, “Compliance Q&A: False Claims Agreements Signal Regulatory Focus on MA Marketing,” was published by AIS Health – Radar on Medicare Advantage on April 4 and is available online (subscription required).