Radar on Medicare Advantage

After more than a decade of fighting False Claims Act allegations regarding its use of chart reviews to find additional diagnoses for risk adjustment purposes, UnitedHealth Group this week notched a major win with a recommendation from a retired judge, who was appointed by a federal court to weigh in on the longstanding case. The order, if followed by the U.S. District Court for the Central District of California, could have important implications for so-called “one-sided” chart reviews — in which insurers like UnitedHealthcare seek additional codes that doctors may have failed to include in submitting claim forms — and the question of whether those reviews should also be used to verify previously submitted codes.

The case (U.S. ex rel. Benjamin Poehling v. UnitedHealth Group, Inc.,16-08697) dates to 2011, when whistleblower Benjamin Poehling filed a civil fraud complaint against his former employer. The Dept. of Justice (DOJ) intervened in 2017, and it amended its complaint-in-intervention in 2018 after a California federal judge dismissed the government’s claims targeting the insurer’s alleged submission of false Risk Adjustment Attestations. At the time, the judge said the government could proceed with its allegations that UnitedHealth failed to remove invalid diagnoses when submitting claims for risk-adjusted payments to the government.

As the Trump administration continues to downsize the federal government, the General Services Administration (GSA) this week posted a list of 440 “non-core properties” it intended to sell, including the four buildings that serves as CMS headquarters, then promptly took the list down. Located in Woodlawn, Maryland, a suburb of western Baltimore County, the CMS complex was completed in 1995. Sources say it’s hard to imagine how CMS can adequately operate Medicare, Medicaid and the Affordable Care Act marketplace with limited operational capacity, even with a diminished workforce. Options include relocating employees to limited space within the HHS headquarters at the Humbert Humphrey Building in Washington, D.C., or to one of CMS’s 10 regional offices, although neither is likely to save much money and would, as one anonymous source put it, “likely disaffect long-serving staff (though that might be part of the plan).” Local news organization WBALTV.com posted a list of 83 federal properties for sale in Maryland. A previously posted list of non-core properties on March 5 was missing from the GSA website.

As Humana Inc. pursues a Star Ratings lawsuit against the federal government with an estimated $3 billion in quality bonus revenue at stake, a new filing maintains that three disconnected calls should be excluded from the calculation of certain measures. In what one analyst called the “strongest counter-argument that CMS has made in any of the Medicare Stars lawsuits,” the Trump administration’s Feb. 7 response to Humana’s prior motion for summary judgment argued that Humana’s case is vastly different from other Stars-related legal challenges.    

Prior to CMS’s October release of the 2025 Star Ratings, Humana disclosed that the percentage of members enrolled in highly rated plans would plummet from 94% to 25% in 2025 — which it attributed to “narrowly missing higher industry cut points on a small number of measures,” including call center measures. Humana appealed the measures via the administrative process, then sued the federal government after the publication of the Star Ratings, claiming it was “denied an opportunity to determine why the measure-level cut points moved so suspiciously in the 2025 scores” and that the agency “refused to share information necessary for Humana to verify the agency’s work in time to make corrections.” Humana alleged that CMS violated the Administrative Procedure Act (APA) by failing to follow its own regulations when administering the ratings.

Following presidential directives to root out sources of financial waste and trim the federal workforce, an untold number of HHS firings occurred from Valentine's Day through President’s Day within agencies including CMS, the FDA and the U.S. Centers for Disease Control and Prevention, according to news reports. By midweek, LinkedIn feeds were inundated with federal jobseekers, including at least a dozen from the CMS Center for Medicare and Medicaid Innovation (CMMI). At the same time, eight recently fired inspectors general, including notable Medicare Advantage watchdog Christi Grimm, sued the federal government and President Donald Trump asserted new authority over rulemaking and enforcement.

As the new administration digs around for ways to cut costs, two recent studies highlight the drivers of overpayment in Medicare Advantage and suggest potential reforms. In one, researchers suggest that excluding the top 10 diagnosis groups from the Medicare Advantage risk adjustment model would slash billions in overpayments and level the playing field between MA and original, fee-for-service (FFS) Medicare. And a separate analysis proposes applying different coding intensity reductions based on individual MA organizations’ level of upcoding.

MA plans report diagnosis codes more thoroughly than FFS, leading to higher risk scores and, consequently, higher payments — a practice known as coding intensity. Critics have held that coding intensity creates a significant discrepancy in payments between MA and FFS, and they say it raises concerns about the fairness and sustainability of the MA program. The Medicare Payment Advisory Commission (MedPAC) estimates that as a result of coding intensity, MA plans were overpaid by more than $50 billion in 2024 alone.