Elevance said it was “surprised and disappointed” by a recent CMS sanction threat, which would suspend enrollment in Medicare Advantage prescription drug plans, CFO Mark Kaye said March 10 at the Barclays 28th Annual Global Healthcare Conference in Miami.
The executive claimed Elevance flagged provider-submitted diagnosis codes and shared information with CMS “in good faith.”
“The issues CMS raised relate to historical risk-adjustment processes. They do not reflect our current operating processes or practices,” he said.
Mr. Kaye said he views the issue as a misalignment with policy interpretation.
“This is not simply a data submission issue. We view this as a broader policy and payments dispute about how retroactive corrections should be treated under the risk-adjustment framework that was in place during that period,” Mr. Kaye said. “This is a disagreement over the interpretation of policy. It’s not an unwillingness to correct inaccurate data.” He said the rules at the time were in line with Elevance’s conduct.
At the conference, Mr. Kaye also said there should be comparable standards for Medicare Advantage and fee-for-service Medicare when it comes to audits and corrective actions. However, he said the company promptly responded to CMS to tackle lingering concerns.
Mr. Kaye said there would be no impact to benefits for current Medicare Advantage members and does not foresee major implications for Elevance’s Medicare business. In terms of financial impact, he said it is too early to gauge.
“The reality is this process remains in its early stages, and we are engaged in discussions with CMS, and we are evaluating all avenues of resolution,” he said.
CMS sent a letter to Elevance outlining its plans to suspend enrollment as a result of alleged “substantial and persistent noncompliance with Medicare Advantage risk-adjustment data submission requirements.”
Elevance had 1.9 million Medicare Advantage members, as of Feb. 1. The enrollment and communications pause is set to begin March 31.
