/>iAs government scrutiny and enforcement targeting the Medicare Advantage (Medicare Part C) program continued in 2024, the industry’s response to agency actions escalated. Last year also resulted in the first sizable Part D False Claims Act settlement. Year over year, as the number of enrollees in Medicare Advantage plans and Part D plans has steadily increased, the total federal spending on Medicare Advantage and Part D has likewise risen and the spotlight on these programs and those who participate in them has intensified.
As seen in years past, the Department of Justice (DOJ) as well as the two agencies that regulate Medicare Advantage Organizations (MAOs) and Part D plan sponsors (PDP Sponsors), the Centers for Medicare & Medicaid Services (CMS), and the Office of Inspector General for the Department of Health and Human Services (OIG), focused much of their attention on risk adjustment activities. DOJ remained in active litigation against many of the largest MAOs in the country while CMS and the OIG began conducting risk adjustment audits subject to extrapolation. Throughout 2024, the industry challenged CMS’s regulatory actions relating to Star Ratings and rules for communicating with Medicare beneficiaries who are considering Medicare Advantage and Part D plans. Finally, On December 9, 2024, CMS also finalized its updated Overpayment Rule for MAOs and PDP Sponsors in the 2025 Physician Fee Schedule Rule.
With Medicare Advantage expected to remain a top enforcement priority in 2025 and Part D enforcement growing, we anticipate that DOJ and CMS will continue to target the actions not only MAOs and PDP Sponsors, but also vendors and third-party entities that touch the Part C and D programs. In 2025, we will also be closely watching for court decisions in ongoing litigation matters that will undoubtedly influence future theories of liability and test the strength of defenses raised by MAOs, PDP Sponsors, and their vendors.
Recent Settlements Demonstrate that DOJ’s Enforcement Interest Spans the Industry
In 2024, DOJ settled two notable False Claims Act (FCA) matters relating to Medicare Advantage, which demonstrate that DOJ’s enforcement interests are not limited to MAOs, but also include vendors and other third-party entities engaged in risk adjustment practices and more. Plus, DOJ settled a large Part D matter relating to how drug costs are reported to and impact Medicare Part D payments from CMS.
Last year, Principal Deputy Assistant Attorney General Brian M. Boynton underscored DOJ’s “commitment to holding accountable third parties that cause the submission of false claims” and the government’s intention to “expand its focus on the Medicare Part C Program to include an examination of the role that vendors and providers play in the diagnoses that are submitted to the government.” DOJ made good on this promise.
For example, DOJ targeted entities involved in marketing efforts to Medicare Advantage patients. In September, Oak Street Health (Oak Street) agreed to pay $60 million to resolve the government’s allegations that it paid kickbacks to third-party insurance agents in exchange for recruiting Medicare beneficiaries to Oak Street’s primary care clinics in violation of the FCA. More specifically, DOJ alleged that Oak Street violated the Anti-Kickback Statute when, in exchange for referring Medicare beneficiaries to Oak Street, Oak Street paid insurance agents (who were acting as agents for MAOs) $200 per beneficiary referred or recommended to Oak Street’s primary care clinics. DOJ further alleged that the insurance agents delivered targeted messages to eligible seniors designed to generate interest in Oak Street and that the payments received incentivized those agents to base their referrals and recommendations on the financial motivations of Oak Street rather than the best interests of seniors. The complaint was filed by a relator who partnered with insurance agents and was contacted by Oak Street, and DOJ intervened in September for purposes of settlement. Although this settlement was with a provider organization (as explained further in), the conduct focused on Medicare Advantage members and their interactions with agents and brokers. CMS similarly highlighted its concerns regarding misleading communications to Medicare beneficiaries in its updated Medicare Advantage and Part D communication rules discussed below.
DOJ also reached a settlement agreement with a risk adjustment coding vendor this December. DOJ kicked off the holiday season by announcing the long-awaited settlement with MAO Independent Health Association, its wholly owned subsidiary and risk adjustment vendor DxID, and DxID’s former CEO, totaling up to $100 million across the three defendants. The government alleged that DxID improperly coded diagnoses from member medical records to inflate Medicare’s payments to Independent Health, including by coding from improper sources, coding conditions for which patients were not treated, and sending addenda to providers months or years after the service occurred. The parties have seemingly been engaged in settlement discussions for years, jointly requesting continual extensions of time for defendants to answer DOJ’s complaint since 2023.
Under this settlement structured based on Independent Health’s ability to pay, Independent Health will make guaranteed payments of $34.5 million and contingent payments of up to $63.5 million on behalf of itself and DxID, which ceased operations in 2021. DxID’s CEO, Betsy Gaffney, will independently pay $2 million. While Independent Health did not admit fault under the settlement agreement, the MAO also entered into a five-year Corporate Integrity Agreement (CIA) with HHS-OIG requiring that Independent Health hire an Independent Review Organization to annually review a sample of its Medicare Advantage beneficiary medical records and its internal controls to help ensure appropriate risk adjustment payments.
Additionally, following years of CMS voicing concerns over Part D Direct and Indirect Remuneration (DIR) and beneficiary protections, DOJ for the first time settled a significant matter relating to Part D DIR reporting. In July, DOJ entered into a settlement agreement with Elixir Insurance Company (Part D plan sponsor), Rite Aid Corporation (Parent Organization), and Elixir Rx Solutions (PBM) for a total of $121 million to resolve allegations that the defendants failed to appropriately report drug rebates through the Medicare Part D DIR reporting mechanism that is used by CMS to reconcile and calculate payments to Part D plan sponsors. Because Rite Aid Corporation, the parent organization, had declared bankruptcy, a portion of the settlement ($20 million) was granted as an allowed, unsubordinated, general unsecured claim in Rite Aid’s bankruptcy case in the District of New Jersey.
This is the first substantial Part D settlement focusing on Part D DIR, and it aligns with a theory of liability that DOJ has been considering for almost a decade. DOJ alleged that amounts that should have been reported as DIR (and therefore would have reduced the amount of revenue the government would pay a PDP Sponsor) were instead falsely reported as fees that do not qualify as DIR, and therefore the PDP Sponsor received and retained government payments to which it was not entitled.
Ongoing Litigation is Likely to Shape Risk Adjustment Enforcement in 2025 and Beyond
As previewed in last year’s report, DOJ continued to litigate three large FCA risk adjustment-focused cases last year against United Healthcare, Kaiser Foundation Health Plans and their affiliated medical groups, and Anthem. Because DOJ’s regulatory expectations of MAOs are often borne out through enforcement actions, judicial instruction on this topic is likely to shape future government actions and exemplify the standard of due diligence MAOs are expected to uphold when engaging in risk adjustment coding activities.
We summarized the current status and next steps for these three key cases below:
- UnitedHealthcare. Litigation continued last year between the country’s largest MAO and DOJ in US ex rel. Poehling v. UnitedHealth Group, Inc. et al. (C.D. Cal.), reaching a key milestone this summer when the parties filed cross motions for summary judgment. In its Complaint in Intervention filed back in 2017, DOJ alleged that United failed to delete inaccurate diagnosis codes that it knew were unsupported by the medical records and thus resulted in overpayments. As one of the few Medicare Advantage lawsuits to reach this stage of litigation, we are watching closely for a summary judgment decision in the new year focused on the elements required to prove liability under the FCA’s reverse false claims provision.
- Anthem. The government raised similar allegations against Anthem in United States v. Anthem, Inc. (S.D.N.Y), arguing that Anthem failed to identify and remove inaccurate diagnosis codes as part of its chart review program. DOJ and Anthem spent 2024 litigating discovery disputes and are set to remain in discovery through 2026.
- Kaiser. DOJ also remained in active discovery with Kaiser in the lawsuit US ex rel. Osinek v. Kaiser Permanente (N.D. Cal.). The government’s Complaint in Intervention, filed in 2021, focuses on Kaiser’s use of addenda in medical records. DOJ alleges that Kaiser pressured physicians to create addenda often months after the patient encounter to retroactively add unsupported diagnoses, and that Kaiser used “data mining” programs to identify missed diagnoses and create the addenda. Following the denial of Kaiser’s motion to dismiss, the parties spent 2024 litigating discovery disputes before a magistrate judge. The case will remain in the discovery phase at least through 2025, with dispositive motions not scheduled until 2026, and a trial date currently set over two years out in 2027.
CMS and The OIG Take Active Role in Regulating Medicare Advantage and Part D with New Rules and the Impact of Extrapolation
Similar to DOJ’s expanded enforcement approach discussed above, both CMS and the OIG continued to focus on risk adjustment activities while CMS also began more heavily regulating agents and brokers who communicate with Medicare beneficiaries.
Risk Adjustment, RADV Audits, and Overpayment Rule: As it relates to risk adjustment, the OIG issued a second report concerning MAOs’ alleged use of in-home health risk assessments (IH-HRAs) to drive up payments. IH-HRAs are exams conducted by health care providers (typically nurse practitioners) in a member’s home to collect information regarding that patient’s health. In its report, the OIG identified 20 MAOs that it believes are outliers for their use of IH-HRAs as a tool to report diagnoses of their members to CMS. The OIG published a similar report in 2021 concluding that IH-HRAs and chart reviews are vulnerable to misuse by MAOs, which has likely driven DOJ enforcement action targeting these practices since.
CMS and the OIG regularly conduct audits of the diagnosis codes that MAOs submitted for their members. Critically, in 2024, the OIG finalized and CMS initiated risk adjustment audits that reached Payment Year (PY) 2018, which is the first year that extrapolation under the CMS final rule applies. Under this rule (42 C.F.R. 422.310(e)) which was finalized in February 2023, CMS has the authority to extrapolate risk adjustment audit findings covering diagnosis codes MAOs submitted in PY 2018 and forward. For years prior to PY 2018, MAOs have only had to repay overpayments identified in the actual sample that CMS or the OIG reviewed.
Last year CMS selected the MAOs that will be subject to PY 2018 Risk Adjustment Data Validation (RADV) Audits and has initiated that process with the selected MAOs. The OIG has already completed certain audits that include PY 2018 and the monetary impact of extrapolation of the findings is immediately apparent. For example, Humana’s final report for diagnosis-targeted audits imposed an overpayment obligation of just $274,000 for diagnoses audited from PY 2017 (no extrapolation) as compared to over $6.5 million in estimated overpayments for diagnosis codes audited from PY 2018 (with extrapolation). Similarly, Health Assurance of Pennsylvania’s final report auditing diagnosis codes in PYs 2018 and 2019 with extrapolation totaled $4.2 million in overpayments.
Additionally, in early December, CMS finalized the Overpayment Rule that requires MAOs and Part D plan sponsors to report and return overpayments within 60 days of an identification. The Rule was initially adopted in 2014 and held MAOs and Part D plan sponsors to a “reasonable diligence” standard when determining when an overpayment had been “identified.” The “reasonable diligence” standard was struck down in United Healthcare Insurance Company v. Azar when the district court held that the standard was impermissibly being used to establish False Claims Act liability. The updated Overpayment Rule, proposed in December 2022, has now replaced the “reasonable diligence” standard with the knowledge standard from the False Claims Act. An MAO is now considered to have “identified” an overpayment when it knowingly (either with actual knowledge, or through reckless disregard or deliberate ignorance) receives or retains an overpayment.
Medicare Advantage and Part D Communication Rules: CMS adopted changes to the Medicare Advantage and Part D Communication regulations for 2025 that, according to CMS, seek to increase transparency and protect Medicare beneficiaries from receiving misleading information about coverage options. CMS expressed concern that agents and brokers who were contracted with MAOs and Part D plan sponsors were enrolling beneficiaries into plans based on which plans paid the agents and brokers the most money, rather than the plan that was in each beneficiary’s best interests.
To address this concern, the revised regulations: (1) prohibit MAOs and Part D plan sponsors from having contract provisions that could directly or indirectly create an incentive that would reasonably be expected to inhibit an agent or broker’s ability to objectively assess and recommend which plan best fits the health care needs of the beneficiary, (2) recognize that MAOs and Part D plan sponsors may pay agents and brokers and Third-Party Marketing Organizations (TPMOs) for certain administrative and overhead expenses but limit the payment for such services to $100 per member enrolled by the agent, broker, or TPMO, previously there was no express limit other than that the values of such payments must not exceed those within the market), and (3) adopt more stringent consent requirements needed in order for a beneficiary’s information to be shared by a TPMO with a third party, including related third parties. As described further below, many entities that provide agent and broker services, referred to as field marketing organizations, or FMOs, sued CMS over these rule changes.
Following these regulatory changes and DOJ actions against brokers and agents, the OIG also weighed in when in December it issued a Special Fraud Alert warning the industry regarding its perceived risks of marketing arrangements between MAOs and health care providers or between providers and agents and brokers for MAOs. We discuss this alert further in our article here.
Industry Actions are on the Rise following the Demise of Chevron Deference
As has been widely reported, the US Supreme Court issued in June a landmark decision in Loper Bright Enterprises v. Raimondo, which struck down the longstanding doctrine of so-called “Chevron deference” to federal agency interpretation of ambiguous statutes and substantially expanded judicial review of such statutes. As expected, Loper Bright has already led to increased scrutiny of, and challenges to, agency action, including in the Medicare space. While “enforcement” against agencies is not typical government “enforcement,” it affects government enforcement matters because it impacts how agencies can take enforcement actions and what rules are enforceable.
In May 2024, certain FMOs sued CMS in the United States District Court for the Northern District of Texas, seeking to invalidate certain portions of the 2025 Medicare Advantage and Part D Communications regulations. The FMOs argued that the provision of these rules, summarized above in the Medicare Advantage and Part D Communication Rules section, violated the Administrative Procedure Act (APA). They argued that the rule was arbitrary and capricious under the APA, claiming that CMS finalized the rule based on “pure speculation,” ignored objections from the public, and failed to acknowledge reliance interests of brokers. The FMOs further contended that the rule failed to properly adhere to the notice and comment procedural requirements because CMS relied upon evidence not presented during notice and comment rulemaking. Less than a week after the Loper Bright decision, the court granted the FMOs’ request for a preliminary injunction relating to the regulation that restricted contract terms and limited administrative fee payments, finding that the rules were not reasonable.
Also, last fall four of the largest MAOs, UnitedHealthcare, Centene, Elevance, and Humana, all challenged how CMS calculated their specific Star Ratings, and, more recently, at least two Blues plans have also sued CMS. Star Ratings is the system that CMS uses to rate the performance of MAO and PDP plan sponsors. A plan’s Star Rating impacts how and when it can be marketed, and in Medicare Advantage, impacts how the plan is paid and when CMS can terminate a plan’s contract. United and Centene’s cases were relatively similar, focusing on how CMS evaluated and calculated a certain call center measure. Humana and Elevance each had arguments specific to their circumstances, and also included broader complaints regarding how CMS calculates Stars. Humana specifically challenged CMS’s unwillingness to share industry data with MAOs to ensure appropriate calculations. On November 22, 2024, the Eastern District of Texas granted summary judgment for UnitedHealthcare and ordered CMS to recalculate the MAO’s Star Rating by removing the one call center measure in dispute. In early December, Centene reported that CMS recalculated its Star Rating for 2025 following its challenge. The other cases are ongoing.
The challenges to Star Ratings are an important enforcement development because these lawsuits may force CMS to rethink how it operates the Star Ratings program and may impact whether CMS can terminate contracts that CMS believes are low performing.
Conclusion
Following another year of intense scrutiny, the Medicare Advantage industry is set to remain a government enforcement priority in 2025, and PDP plan sponsors will likely attract similar scrutiny. Both MAOs as well as third-party entities involved in the Part C program should continue to monitor DOJ enforcement activity and decisions in ongoing litigation to evaluate their risk adjustment practices. Moreover, with the danger of extrapolation of risk adjustment audits evident, MAOs must be mindful to engage in robust compliance efforts and to review published OIG reports and related guidance to mitigate enforcement risk. PDP Sponsors and their vendors should expect increased scrutiny following the Elixir settlement, the continued rollout of the Inflation Reduction Act and the intense national discussion regarding prescription drug costs. We will continue to monitor the evolving enforcement actions against MAOs and PDP Sponsors and watch closely for updated guidance whether via agency regulations and reports or court decisions in 2025 and beyond.
