05-February-2016

According to an article in Medicare Advantage News, experts believe the Centers for Medicare and Medicaid Services (CMS) will implement more robust regulatory scrutiny and enforcement measures for Medicare Advantage (MA) plans in the coming year. Experts forecasted “enhanced MA regulatory scrutiny” in a host of areas, including “provider-network adequacy, risk scores, health risk assessments, medication therapy management, and fraud, waste and abuse,” the article said.

Mike Adelberg, senior director for FaegreBD Consulting, flagged network adequacy and risk adjustment as the areas likely to receive the most attention from CMS. Specifically, in the coming months Adelberg expects CMS to decide if it will measure MA plans provider networks, not only via submitted data, but also through the establishment of a national provider database or with something “less centralized” such as the machine-readable provider network files being used by the federally-run health insurance exchanges. He also said MA plans should expect CMS to take a firmer hand in auditing MA plans’ risk-adjustment data.

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