Risk, Reform, and Responsibility: Navigating Medicare Compliance with Charles Baker
In this episode of Health Law Simplified, hosts Sandy Durkin and Elizabeth Lippincott welcome Charles Baker, Vice President of Compliance Solutions at ATTAC Consulting, for a deep dive into the evolving landscape of Medicare Advantage compliance. From the operational impact of RADV audits and the philosophical roots of risk adjustment to the implications of the No UPCODE Act and the future of in-home HRA assessments, Charles shares his unique perspective shaped by years in social work, academia, and health plan leadership. Tune in for a candid conversation on how managed care organizations can align regulatory demands with meaningful patient care.
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50:45
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50:45
RADV Audits: Will CMS Crackdown Alter the Medicare Advantage Landscape?
In this episode of Health Law Simplified, we unpack a major shift in Medicare Advantage oversight: CMS’s sweeping expansion of its Risk Adjustment Data Validation (RADV) audit program. Beginning immediately, CMS will significantly expand its oversight by auditing all 550 eligible Medicare Advantage contracts each year – an ambitious leap from the previous annual review of just 60 plans. Hosts Sandy Durkin and Elizabeth Lippincott explore why CMS is cracking down, how it's scaling up with new technology and a 50-fold increase in medical coders, and what this means for health plans and providers. They break down the legal and financial implications of extrapolated audit findings, including the risk of large recoupments, and talk about their expectations for the extrapolation methodology for targeted audits. This episode offers critical insights and practical steps to prepare for one of the most consequential oversight changes Medicare Advantage plans have seen.
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29:11
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29:11
DOJ Targets Medicare Advantage Marketing
This episode of Health Law Simplified unpacks the U.S. Department of Justice’s False Claims Act lawsuit against major Medicare Advantage insurers and brokerages. The DOJ alleges illegal kickbacks and discriminatory practices targeting disabled beneficiaries. The episode also explores CMS’s 2025 Final Rule on broker compensation, its legal challenges, and the broader implications for compliance, marketing ethics, and regulatory enforcement in the Medicare Advantage space.
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34:19
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34:19
Finding Stability in the Medicare Advantage Landscape
In this episode, Elizabeth and Sandy delve into the latest updates in the Medicare Advantage and Part D landscape. Our word of the year, "stability," sets the tone as we explore the implications of the CMS final rule for 2026, which finalizes several Biden-era proposals. We discuss the key changes in the rule, including new guardrails for supplemental benefits and the Medicare Prescription Payment Plan, and highlight what was notably left out of the rule. Additionally, we cover the CMS rate announcement and the rebranding of the health equity incentive program to "Excellent Health Outcomes for All (EHO4all)," set to be implemented for the 2027 Star Ratings. Lastly, we examine the recent developments in the risk adjustment litigation against UnitedHealth Group, focusing on the special master's report and its potential impact on MA plans.
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39:17
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39:17
Looking Under the Hood of Medicare Advantage with Molly Turco
We talk with Molly Turco, who served as Senior Policy Advisor on Medicare Advantage (MA) and Medicare Part D at the Center for Medicare at the Centers for Medicare & Medicaid Services until leaving the agency in January. Molly unpacks updates in MA policy and reimbursement, including the v28 risk adjustment model and prior authorization.
Health Law Simplified℠ breaks down the latest legal developments, challenges, and regulatory impacts in managed care—giving business leaders the insights they need to stay ahead. Join attorneys Elizabeth Lippincott, Sandra Durkin, and Katarina Weessies each month for practical, engaging conversations about the ever-evolving world of health law.
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