As Medicare Advantage attracts more eligible beneficiaries, it is also drawing attention from False Claims Act (FCA) prosecutors. In 2022, enrollment in Medicare Advantage plans reached 28.7 million Medicare beneficiaries, or 49% of eligible beneficiaries. Recently, the United States intervened in a qui tam case against Cigna filed in the Southern District of New York and later transferred to the Middle District of Tennessee. The government’s intervention in Cigna is the latest example of high-profile Medicare Advantage cases against prominent insurers. This reflects the government’s conviction that, as Medicare Advantage’s share of the healthcare market grows, many Medicare Advantage plans are manipulating the risk adjustment process (RAP) to fraudulently obtain higher payments from the federal government.
Unlike traditional Medicare Parts A and B, Medicare Advantage (Part C) does not directly reimburse healthcare providers for services rendered. Instead, Medicare pays private insurance companies a capitated, or fixed, rate for care to Medicare Advantage beneficiaries. This rate is determined, in part, by a complex RAP that factors in the beneficiaries’ relative health, as well as diagnoses codes. Certain diagnoses increase the amounts paid for the beneficiary.
In addition to the lawsuit against CIGNA, the government is also involved in suits against other large insurance companies, including Kaiser Permanente in the Northern District of California (United States ex rel....
Iran’s Supreme Leader Mojtaba Khamenei is in "good health" and suffered only minor injuries during the February 28 strikes, senior Iranian officials said on Friday, dismissing mounting speculation...