July 2, 2025
Medicare Advantage RADV Update: Tons More PY19 Audits, UNH Has the Most For Now
CMS’s addition last week of 300+ Medicare Advantage (MA) [UNH, HUM, CNC, ELV, CVS, ALHC] contracts to be audited for risk adjustment data verification (RADV) during plan year (PY) 2019 raises the risk of larger…
June 16, 2025
Medicare Advantage: Filling in RADV Blanks; HUM Has Most Contracts Targeted [HUM, UNH, CVS, ELV, CNC, ALHC]
Late Friday, CMS announced the latest list of Medicare Advantage (MA) contracts to be targeted for risk adjustment data verification (RADV) audits – this time for payment year (PY) 2019 – and its associated processes…
June 13, 2025
PBMs: State Legislative Risks Persist Through Session Ends [CI, CVS, UNH, HUM, ELV, Navitus]
With many 2025 state legislative sessions having concluded, pharmacy benefit managers (PBMs) have – for the moment – successfully avoided various bills seeking to aggressively curb industry practices, except for a few new laws in…
June 6, 2025
Thoughts on Medicare Savings Ideas in Reconciliation
Yesterday’s news reports that Senate Republicans are considering and discussing Medicare savings policies to add to the reconciliation bill for lowering the overall deficit and/or filling any potential hole from softening some of the House’s…
May 21, 2025
Medicare Advantage: Ramping Up RADV Audits Clearly a Threat, But Does It Head Off Other Risks? [HUM, UNH, CVS, ELV, ALHC]
CMS’s announcement late Wednesday to turn the dial up on its risk-adjustment data verification (RADV) audits of Medicare Advantage (MA) contracts with an eye toward the entire landscape raises legitimate fears of recouping sizable past…
April 10, 2025
[CVS, CI, UNH]: Senate Confirmation of 3rd FTC Commissioner Allows for Future Resumption of PBM Litigation
Today’s successful Senate confirmation of Mark Meador to join the FTC as a commissioner paves the way for the FTC to officially resume its antitrust litigation against the pharmacy benefit managers (PBMs) [CVS, CI, UNH,…
April 7, 2025
[HUM, ALHC, UNH, CNC, AGL, PRVA]: MA’s 5%+ Increase Met Our Expectations, But Longer-Term Coding and Part D Questions Remain
The final CY26 Medicare Advantage (MA) rate announcement met our previously-published optimistic expectations for a comfortable mid-single-digit YoY benchmark rate increase for MA insurers [HUM, ALHC, UNH, CVS, ELV, CNC] with CMS finalizing a 5.06% increase, largely…
April 6, 2025
[HUM, ALHC, UNH] Final Medicare Advantage Tech Changes Reg: Most Proposals Dropped Without Explanation, Await CY26 Rate Notice
CMS’s final CY26 technical changes rule for Medicare Advantage (MA) and Part D plans [HUM, ALHC, UNH, CVS, ELV, CNC] lived up to expectations of rolling back proposed restrictions in response to consumer complaints, but…
March 25, 2025
HUM, ALHC, UNH: Optimistic for Mid-Single Digit MA Rate Increase for CY26, Upcoding Remains a Longer-Term Issue
Anticipating CMS’s issuance of its final CY26 Medicare Advantage (MA) rate notice within the next two weeks (on or before Monday, April 7), we remain optimistic about near-term regulatory changes for MA insurers [HUM, ALHC,…
March 14, 2025
Oz Nomination: Moving towards Senate Confirmation, Medicare Advantage Comments Show Mixed View
Today’s Senate Finance Committee confirmation hearing of Dr. Mehmet Oz as Trump’s CMS Administrator provided limited new insights into his approach to Medicare, Medicaid, Obamacare, pharmacy benefit management reforms, health savings account adoption, and healthcare…