Distance Learning

Medicare Advantage Risk Adjustment and False Claims Liability (Intermediate) - On Demand Recording

Recorded On: 10/16/2015

Time: 75 minutes

Whether Medicare Advantage (MA) plans do it themselves, or hire a contractor to submit risk-adjustment data to the Centers for Medicare & Medicaid Services (CMS), the Medicare risk-adjustment process is fraught with potential liability landmines. CMS pays MA plans more money for enrollees with more serious and costly medical conditions based on the risk-adjustment data submitted by MA plans. But risk-adjustment data that is inaccurate or based on ineligible members can expose an MA plan to fraud and false claims liability. It is critical that MA plans ensure the accuracy and integrity of the risk adjustment data submitted to CMS. This roundtable discussion will feature two health care attorneys who will address compliance and liability issues involved with Medicare risk adjustment and CMS' Hierarchical Condition Category (HCC) model. Included will be discussions regarding:

  • An overview of the Medicare Advantage risk adjustment process;
  • Advice on oversight mechanisms and other operational controls;
  • A review of key program integrity developments related to risk adjustment encounter data;
  • A review of key regulatory, contractual, and operational requirements affecting potential for managed care False Claims Act claims;
  • The recent focus in Washington, DC on the Medicare Part C HCC/risk adjustment program;
  • An overview of the False Claims Act and its application to Medicare contractors;
  • Developments in False Claims Act cases alleging improprieties in the HCC/risk adjustment process; and
  • Predictions about what the future may hold for false claims act cases involving risk adjustment.

Level of Difficulty: Intermediate

Intermediate-level programs generally offer focused discussions regarding common legal issues pertaining to the program topic. Intermediate programs include legal updates and changes in the law. Speakers will assume the audience has a working knowledge of this specialty of health law, and there will be limited review of the fundamentals. This program is designed to provide a targeted, comprehensive analysis of the subject matter for those practicing law in this specialty for three to seven years and/or those whose practice is periodically focused in the covered subject area.

Sponsoring AHLA Groups:

  • Fraud and Abuse Practice Group
  • Health Care Liability and Litigation Practice Group
  • In-House Counsel Practice Group
  • Payers, Plans, and Managed Care Practice Group

​Peter Roan, JD


Crowell & Moring LLP
Los Angeles, CA

​Jonathan Hendrickson, FSA, MAAA

Principal, Consulting Actuary

Phoenix, AZ

Distance Learning Event Recordings

Recordings of past webinars, roundtable discussions, and educational calls are not eligible for Continuing Legal Education (CLE) credit. CLE credit may be obtained by applying directly to the attorney's state accrediting body, but approval is not guaranteed and is at the discretion of said accrediting body and subject to its rules and regulations. Please refer to the Distance Learning CLE State Chart for details regarding specific state guidelines.

For additional information about Distance Learning-related credits, please email the Practice Groups staff at pgsce@healthlawyers.org.

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