Medicare Advantage is the fastest-growing portion of the health insurance market, but its unique and often complex payment models present significant challenges for providers. Frier Levitt has extensive experience representing entities operating under risk-adjusted capitated arrangements as well as vendors in this space – including IPAs, ACOs, and healthcare data consulting companies – in resolving complex disputes with payors, including Medicare Advantage Organizations (MAOs) and Pharmacy Benefits Managers (PBMs).
Our team combines deep healthcare regulatory knowledge with sophisticated litigation and compliance strategies to help providers protect revenue, ensure regulatory compliance, and hold payors accountable.
Pre-Litigation Risk Adjustment Due Diligence
Before entering litigation, providers and vendors often benefit from a comprehensive review of their Medicare Advantage contracts and payments to identify revenue leakage or noncompliance. Frier Levitt helps answer critical questions such as:
- Are payors improperly withholding data or revenues?
- Are MAOs charging you for costs that are not reimbursable under Medicare?
- Are they billing for programmatic, non-clinical costs (e.g., certain VBID costs) that could have fallen under capitated arrangements?
- Are they charging you for costs expressly non-reimbursable under Medicare?
- Are MAOs and their affiliate PBMs or rebate aggregators “skimming” pharmacy manufacturer rebates that ought to flow to your entity, inflating Part D costs?
- Are the clinical costs you are being charged by MAOs “actual” costs, inclusive of all price concessions MAOs and their affiliates receive?
- Are vendors with gainsharing agreements tied to the identification of Dx codes – how can you be sure your client has paid you a percentage of what they actually earned?
Litigation and White Collar Defense Services
When disputes escalate, Frier Levitt provides aggressive representation for providers and vendors in federal courts and arbitration forums such as the American Arbitration Association (AAA).
Our services include:
- Risk Adjustment Litigation against MAOs, PBMs, and Managed Medicaid Organizations for breach of value-based care contracts.
- Civil Investigative Demand (CID) response and strategy, including negotiating scope with federal or state agencies and preparing preemptive defenses.
- False Claims Act defense for risk adjustment-related investigations or cases, high-stakes matters requiring specialized healthcare fraud and compliance expertise.
Medicare Advantage Compliance Services and Regulatory Counseling
Compliance is critical in risk adjustment to avoid government scrutiny and financial exposure. Frier Levitt advises providers on:
Ensuring agreements comply with appropriate safe harbor of key healthcare laws, including the Federal Anti-Kickback Statute, and other key healthcare regulations.
Developing standard operating procedures (SOPs) and training programs for your physicians and coders to ensure compliance with ICD-10 Coding Guidelines and CMS Guidance.
Evaluating and mitigating problematic coding practices within your own entity or by a vendor, including OIG Self-Disclosure protocols where appropriate.
Contracting, Payment Auditing, and Appeals
Frier Levitt can assist your practice in negotiating global capitated risk arrangements, auditing MAO-payments made under preexisting arrangements, and in appealing MAO fee-for-service claims denials. Our services include:
- Working with data scientists and actuaries to determine payor compliance with value-based care contract payment provisions (e.g., evaluating accuracy of payor-assigned patient risk scores in a globally capitated payment model, assessing the accuracy of a shared savings/risk determination).
- Leveraging pre-litigation dispute resolution with payors – both private and governmental – to recover underpayments or challenge excessive shared risk assessments.
- Litigating breach of value-based care contracts against commercial carriers, Medicare Advantage Organizations, and Managed Medicaid Organizations.
- Drafting SOPs and provide compliance training to ensure your practice is accurately and compliantly – and comprehensively – capturing and coding patient diagnosis codes affecting the accuracy of patient risk scores and, by extension, the accuracy of risk-score-based payments, such as capitated payments.
- Drafting SOPs and provide compliance training to ensure your Practice avoids even the appearance of having engaged in risk adjustment diagnosis code “upcoding”, a growing issue that has resulted in civil and criminal prosecutions of payors and providers alike.
- Reviewing stop-loss coverage and withholdings or payments to ensure accuracy and appropriate protections for your organization.
- Establishing SOPs and provide compliance training to ensure your practice is compliantly and efficiently addressing all fee-for-service denials or under-reimbursements to determine whether a basis for appeal exists, whether and how a timely appeal may be made.
- Drafting letters of appeal to MAOs or their MACs to maximize reimbursement of claims
Who We Represent
Frier Levitt has represented a diverse range of provider entities or their subcontractors in value-based care related matters, including
- Hospitals
- Self-funded health plans
- Independent and hospital-based medical practices
- Private equity-based medical practices
- Clinically Integrated Networks (CINs)
- Accountable Care Organizations (ACOs)
- Independent Physician Associations (IPAs)
- Healthcare data analytics vendors and risk adjustment service providers
Why Choose Frier Levitt
Decades of experience navigating CMS regulations, value-based care payment models, and risk adjustment disputes.
Collaboration with actuaries and data scientists to build strong cases and maximize recoveries.
Proven track record in defending against government investigations and pursuing payors in court and arbitration.
Contact Us
If your organization is involved in Medicare Advantage risk adjustment contracting, payment disputes, compliance audits, or litigation, Frier Levitt can provide strategic, industry-focused legal counsel tailored to your needs. Contact our team today to learn how we can help you.
