CMS gave a perhaps ill-timed “Christmas present” to Medicare Advantage plans — a Dec. 21 memo outlining processes for the new round of risk adjustment data validation (RADV) audits that will represent the first time it is going to extrapolate overpayment results found to the full MA contract. This, along with an HHS Office of Inspector General (OIG) report a month earlier saying that the PacifiCare unit of UnitedHealth Group was overpaid by nearly $424 million for an MA contract in 2007,... Read more

‘Twas two weeks after another AEP last-minute blitz/ And MA executives were slowly recovering their wits/ The final figures won’t be ready for another few weeks/ But indications are there’ll be more membership peaks/ Lest anyone think, though, all the industry news is cheery/ The executives know that in MA there’s no rest for the weary/ There is no way the mood can be only elation/ When MA could be a casualty if there is sequestration/ Moreover, the plans must try to keep improving in... Read more

There is one message that seems particularly clear in the second annual installment of CMS’s memo previewing upcoming changes in the Medicare Advantage and Part D star ratings. The agency now is willing to give MA plans visibility into what changes it is considering not only for the next year’s star ratings but also for the year after that and beyond, and even to say what plans will need to attain to get a four-star rating in some of the measures for 2015. This change draws praise from MA... Read more

Humana Inc. says it has seen the future of Medicare Advantage, and it looks quite a bit different from what MA looks like today. When the company on Nov. 5 unveiled the planned acquisition of Metropolitan Health Networks, Inc., a Florida-based medical services organization, and purchase of a noncontrolling interest in another MSO and of a health IT firm that links physicians, it made a point of saying they are parts of a new integrated care delivery strategy in Medicare. In some ways, this... Read more

They say that politics makes strange bedfellows, but perhaps Medicare Advantage now might have politics beat. The newly unveiled agreement for huge not-for-profit integrated delivery system Catholic Health Initiatives to buy a controlling interest in non-faith-based, for-profit MA plan Soundpath Health in Washington state may be enough to knock your sheets off. Read more

There was a lot of material — but perhaps not a lot of help for Medicare Advantage plans — in the Risk Adjustment Data Validation (RADV) audit phone call that CMS officials held with MA plans Oct. 9. The agency did elaborate on the procedural steps it will follow for RADV audits for payment year 2011 to determine if plans got the right amount of risk-adjusted payments, but its officials left unanswered the key question of how CMS will calculate the fee-for-service (FFS) adjuster that will... Read more

There were plenty of things to be encouraged about in the Medicare Advantage “landscape files” for 2013 that CMS released Sept. 19. But a closer look also turns up some significant concerns. CMS has correctly pointed to the relatively small average premium increases and widespread availability of large numbers of MA plans as evidence that the MA market now is healthy and that consumers can find attractive plan options. Read more