Radar on Medicare Advantage

As Medicare Advantage insurers seek ways to maximize revenue in a fiscally challenging environment, the accurate and complete capture of diagnosis codes is paramount. That’s because their reimbursement is dependent on the documented health of their enrollees and related risk scores. But risk adjustment comes with inherent compliance risks, demonstrated by pending lawsuits involving the use of chart review and addenda programs and a recent settlement involving whistleblower Teresa Ross, a former MA plan employee who spoke at the 2025 RISE National conference.

“It’s a very isolating and lonely time. The whole time the company is gaslighting you. You say too much, so then you get excluded from meetings,” said Ross. At one point, her employer sent a mental health counselor to her office “to try to tell me that I was wrong for not going along,” she recalled.

During a recent public meeting of the Medicare Payment Advisory Commission (MedPAC), a preliminary discussion about solutions to address misaligned Medicare marketing incentives took an abrupt turn when commissioners suggested eliminating agents and brokers altogether. This caused a stir in the agent and broker community, with the National Association of Benefits and Insurance Professionals (NABIP) promptly seeking to set the record straight on MedPAC’s “flawed assertions.” AIS Health, a division of MMIT, has learned that six members of MedPAC have since agreed to meet with members of the Medicare Advisory group at NABIP.

“I was disheartened and shocked when I heard the amount of misinformation and personal guesswork that was being discussed” at the March 7 MedPAC meeting, says Amanda Brewton, who is a member of the NABIP advisory group and owner of the field marketing organization Medicare Answers Now.

From engaging with patients and scheduling appointments to assisting with chart reviews and predicting fall risk, artificial intelligence can serve a wide range of purposes in Medicare Advantage and will play an increasingly important role in health care delivery overall. That was a prevailing theme at the RISE National 2025 conference, held March 11-14 in San Antonio, Texas, and it was echoed by CMS Administrator nominee Mehmet Oz, M.D., who touted the potential for AI to “optimize care” and reduce fraud, waste and abuse during his March 14 Senate confirmation hearing.

“We’re towards the peak of AI hype,” declared RISE keynote speaker Robby Sikka, M.D., an anesthesiologist and technology innovator who helps sports teams predict athletes’ potential for injuries and anticipate their medical needs. “There’s a lot of data analytics companies and AI companies that I saw downstairs in your vendor show.…There’s a lot of really amazing things that are happening, but it’s going to take time for those companies to evolve and really permeate and make a difference.”

“AI can be used for good or for evil,” stated CMS administrator nominee Mehmet Oz, M.D., during his recent Senate confirmation hearing. Appearing before the Senate Finance Committee on March 14, Oz repeatedly heralded the abilities of artificial intelligence to improve patient care and address fraud, waste and abuse. But reports of Medicare Advantage insurers’ alleged misuse of AI have also eclipsed what many exhibitors and speakers at the recent RISE National 2025 conference view as AI’s potential to be transformative.

Technology in health care has greatly evolved in the last decade, and while the industry is rapidly adopting time-saving tools and predictive analytics that can save lives, it is reaching an “inflection point,” observed Robby Sikka, M.D., in a keynote session at the industry conference, which was held March 11-14 in San Antonio, Texas. Sikka is an anesthesiologist and tech innovator who uses analytics to help sports teams predict athletes’ risk of injuries.

Although Mehmet Oz, M.D., has yet to appear before a second Senate committee, if his smooth testimony before the U.S. Senate Finance Committee on March 14 is any indication, his confirmation as CMS administrator is almost assured. “There is no doubt you are qualified to serve as the next administrator…and I look forward to voting in favor of your nomination and am urging all of my colleagues to do the same,” Chairman Mike Crapo (R-Idaho) declared after Oz handily answered most of the senators’ questions.

When asked by multiple senators (mostly Democrats, whose votes aren’t needed to clinch the nomination) about whether he is in favor of Medicaid cuts, Oz did not provide clear answers. Despite Oz declaring that he and President Donald Trump “love and cherish Medicare and Medicaid,” Sen. Ron Wyden (D-Ore.) was dissatisfied after digging in further and stated, “Let the record show that I asked a witness who said he cherishes this program will you agree to oppose cuts and he would not answer a yes or no question.” Oz did, however, firmly signal support for work requirements in Medicaid.