On April 3, 2025, the US Senate confirmed Dr. Mehmet Oz as the next administrator of the Centers for Medicare & Medicaid Services (CMS). In congressional hearings preceding his confirmation, Dr. Oz testified that he will be the “new sheriff in town,” particularly with respect to Medicare Part C, also known as the Medicare Advantage program (MA Program). As the Trump administration proceeds with its stated efforts to minimize fraud, waste, and abuse in federal programs, health plans and providers involved in the MA Program should be aware of recent developments concerning False Claims Act (FCA) liability and prepare for increased enforcement activity.
The MA Program is the largest component of Medicare, both in terms of federal dollars spent and the number of beneficiaries impacted. Under the MA Program, Medicare beneficiaries enroll in private health insurance plans that offer Medicare benefits (MA Plans). MA Plans are paid a per-person amount to provide Medicare-covered benefits to enrolled beneficiaries. CMS adjusts the payments to MA Plans based on beneficiary demographic information and health conditions. These risk adjustments are determined by an individual’s “risk score”—a number based on the predicted costs for treating a particular beneficiary based on the individual’s diagnoses. In general, a beneficiary with diagnoses that are more expensive to treat will have a higher risk score, and CMS will make a larger risk-adjusted...
A man from Malibu has been convicted of scamming investors and Hollywood stars out of more than $20 million through false claims about his celebrity app’s business performance. Bernhard Eugen Frit...