Value-based care
You need to have it both ways: Audits must target missed coding opportunities and invalid conditions in risk adjustment
By Brian Murphy Among the alleged behaviors that led to Kaiser’s eventual $556M payout to settle false claims act allegations was its aggressive effort to only add diagnosis codes (up to a year or more after the encounter) and never remove them. This is called a one-way audit, and the Department of Justice does not…
Read MoreRisk Adjustment Reality Check: What’s Working—and What Isn’t
Listen to the podcast. This year has been something of a reckoning for Medicare Advantage. Senator Grassley’s scathing report of UHG’s risk adjustment practices, and the Kaiser $556 million settlement to resolve False Claims Act allegations of upcoding, opened eyes, and got many in the industry talking. I wanted to get someone on the show with opinions, unafraid to speak their mind and share their perspective. I’ve found that person. Betty Stump is Senior Solution Consultant…
Read MoreNorwood publishes analysis of CMS 2027 Advance Notice
Download the guide here. Medicare Advantage just shifted again — and 2027 is already reshaping your 2026 strategy. If you think the 2027 Advance Notice is just another routine CMS update… think again. Inside this guide, we break down: 📉 A projected $1.2M funding reduction per 10,000 MA lives 📊 $2.3M impact tied to coefficient…
Read MoreA reckoning for Medicare Advantage: Inside the Kaiser case with Mary Inman and Liz Soltan
Listen to the episode here. Medicare Advantage is undergoing a reckoning … and that reckoning is coming from within. In January Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that it violated the False Claims Act by submitting invalid diagnosis codes for their MA Plan enrollees in order to receive higher payments…
Read MoreA very bad start to the year for Medicare Advantage; whistleblowers and government officials expose questionable risk adjustment coding practices
By Brian Murphy This has been a terrible start to the year for Medicare Advantage. Senator Chuck Grassley’s report “How UnitedHealth Group Puts the Risk in Medicare Advantage Risk Adjustment” landed like a bombshell on Jan. 12. It revealed the extent of UHG’s “robust diagnosis capture workforce,” from advanced analytics to in-home health assessments…
Read MoreDownload The State of Value-Based Care, our latest white paper.
We’re kicking off 2026 with a special report on The State of Value-Based Care. This paper shows where we are nationally with CMS’ stated goal of Every Traditional Medicare beneficiary in an accountable care relationship by 2030. It also offers critical tips and strategy on compliant risk adjustment, depiction of patient illness, and compliance with…
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