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April 27, 2023

Addenda, One-Way Chart Reviews and Other Trends in Upcoding Lawsuits

Virtual Fourth National Medicare Advantage Summit



Jesse Witten presented on “Addenda, One-Way Chart Reviews and Other Trends in Upcoding Lawsuits” for Medicare Advantage Organizations (MAOs) at the Virtual Fourth National Medicare Advantage Summit.

Jesse discussed risk adjustment payments, the coding rules, and Congress’s coding intensity adjustment. He outlined False Claims Act liability and penalties, and defenses based on coding arguments and the actuarial equivalence argument. Illustrative case studies included the 2018 Davita settlement and the 2021 Sutter Health settlement, as well as recent rulings and lawsuits in U.S. ex rel. Osinek v. Permanente Medical Group, U.S. ex rel Ross v. Independent Health Group, U.S. v. Cigna, and U.S. v. Anthem.

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