CMS has taken a series of enforcement actions against Medicare Advantage plans over the last two years, suspending enrollment and terminating contracts over issues ranging from network adequacy to financial solvency failures. Eight updates:
Medicare Advantage
Over a six-year period, Medicare may have spent $380 million on organs that were not ultimately used in covered enrollee transplants, according to a September HHS Office of Inspector General report. Under federal law, Medicare can only reimburse certified transplant…
Medicare Part D sponsors paid pharmacies $587.7 million for some over-the-counter drugs with obsolete prescription-only labels, despite CMS oversight. Medicare Part D does not cover OTC drugs. According to an Aug. 31 HHS Office of Inspector General report, Part D…
CMS has again suspended enrollment for two Medicare Advantage prescription drug plans offered by Boston-based eternalHealth, the second time in less than two years that the insurer has faced sanctions. The agency said Aug. 27 the enrollment freeze on the…
The Justice Department’s scrutiny of Medicare Advantage risk adjustment is intensifying, with two recent settlements totaling nearly $1.1 billion highlighting federal concerns about diagnosis coding practices that can increase payments to health plans. The latest came Aug. 27, when The…
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CMS said its enforcement efforts have resulted in blocking more than $1.6 billion in possibly improper Medicare lab payments throughout President Trump’s administration. An Aug. 28 CMS news release said these enforcement actions included savings of $732 million from 157 providers with…
Federal enforcement around Medicare Advantage risk adjustment and billing has ramped up over the past two years, producing multimillion-dollar settlements with insurers, provider groups, and the vendors that handle their diagnosis coding. The combined value of the settlements comes to…
A federal judge has denied Elevance Health’s request for an emergency recalculation of its 2026 Medicare Advantage star ratings. On Aug. 27, U.S. District Judge Lisa Godbey Wood ruled that Elevance waited too long to file for the emergency recalculation…
The Villages (Fla.) Health, a primary and specialty care provider group, has agreed to pay $541.5 million to resolve allegations that it violated the False Claims Act by submitting improper Medicare Advantage diagnosis codes, according to an Aug. 26 news…
Detroit-based Henry Ford Health saw Medicare Advantage membership climb 45.8% year over year during the first half of 2026 as its insurance business helped drive revenue growth. Seven things to know: 1. Medicare Advantage membership reached 132,566 as of June…