Risk Adjustment, UM Practices Would Be Likely Targets if Lawmakers Pursue MA

With the recent filing of two proposed class action lawsuits against major Medicare Advantage insurers’ use of a computer algorithm to deny patient care, upcoming CMS audits of MA plans’ utilization management (UM) tactics and progressive lawmakers’ push for CMS to collect more data on coverage denials, the MA program is starting the year off under a microscope. And while major new policy developments are unlikely to come out of a split Congress this year, industry experts agree that prior authorization — along with risk adjustment and coding intensity — will continue to garner attention from lawmakers and regulators.

HealthScape Advisors Principal Cary Badger and Managing Director Alexis Seeder Levy point to three possible regulatory scenarios to watch for in 2024: