Medicare Advantage Risk Adjustment Litigation

Medicare advantage word cloudMedicare Advantage is the fastest-growing portion of the health insurance market, but its unique and often complex payment models present challenges many providers are ill-equipped to tackle. Global risk capitated models or other “population health”-based model, for example, anchored to your patients’ risk scores, require probing analysis by healthcare attorneys, data scientists or actuaries to ensure a provider’s Medicare Advantage Organization (“MAO”) is accurately and compliantly calculating scores based on all of your practice’s validly submitted risk adjustment data, such as ICD-10 codes. And even then, further analysis is required to verify your MAO is accurately converting risk scores to dollars and not improperly reducing capitated payments by withholding more than permitted for ancillary costs such as stop-loss coverage. Retaining counsel experienced in this arena to negotiate such contracts or to audit your contract and MAO payment history to ensure fair and accurate payment and to demonstrate to your payor that you are watching it as much as it is watching you, can save your practice tremendous losses in revenue you may never have even realized it had suffered.

Medicare Appeals.  Likewise, in the more standard fee-for-service Medicare Advantage space, far too often providers fail to appeal or properly and effectively appeal payment denials or unlawful under-reimbursements by Plans. Unprosecuted appeals result in tremendous loss in revenue in the aggregate. Indeed, as noted in an Office of Inspector General (“OIG”) “Report in Brief,”1 whereas MAOs “overturned 75 percent of their own denials during 2014-16, overturning approximately 216,000 denials each year [,] . . . beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.” Outsourcing non-reimbursed or under-reimbursed Medicare Advantage fee-for-service claims to competent healthcare counsel to handle could ultimately pay handsome dividends for your practice, while allowing your practice and staff to avoid the time, expense and often highly complex and confusing process of filing effective appeals.

What We Do

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. Such services include but are not limited to: 

Keeping Payors Honest.  Frier Levitt services in this space, 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)
  • Pre-litigation dispute resolution with payors – both private and governmental – to leverage appropriate financial compensation in cases where payors underpay shared savings owed or have assessed too much shared risk against a provider
  • Litigate breach of value-based care contracts against commercial carriers, Medicare Advantage Organizations, Managed Medicaid Organizations, State Medicaid Plans, and Original Medicare

Keeping Your Practice Compliant and Efficient in Light of Value-Based Care Specific Regulations and Guidance

  • Draft standard operating procedures 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
  • Draft standard operating procedures 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
  • Evaluation of whether a practice is properly covered, as may be required, by stop-loss, and analysis to determine whether stop-loss withholdings or payments are accurate and proper

Creating or Improving Your Practice’s Internal Fee-For-Service Medicare Advantage Standards Operating Procedures and/or Assisting in the Effective and Efficient Prosecution of Medicare Advantage Fee-For-Service Appeals

  • Draft standard operating procedures 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, and/or draft letters of appeal to MAOs or their MACs to ensure maximum 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 medical practices
  • Hospital-based medical practices
  • Private Equity-based medical practices
  • Clinically Integrated Networks (CINs)
  • Accountable Care Organizations (ACOs)
  • Independent Physician Associations (IPAs)