Insights: Healthcare

Medicare Advantage (MA) RADV

The Centers for Medicare & Medicaid Services (CMS) issued a statement announcing its intent to restart Risk Adjustment Data Validation (RADV) audits, clear the existing backlog of incomplete audits by early 2026, and boost its auditing workforce/capabilities (i.e., 40 coding experts to 2k, new technology, auditing of every plan, from 35 records...

Medicare Advantage (MA) & UnitedHealthcare

Reports indicate the DOJ has launched a criminal investigation into alleged improper Medicare Advantage (MA) billing practices by UnitedHealth Group (UNH). These reports come on the heels of a similar civil investigation being launched by the agency in February of this year. It is unclear at this stage whether the investigations are separate or...

House Republicans are making a final push to pass their partisan reconciliation (tax/spending) legislation, with President Trump and House conservatives currently meeting at the White House to overcome their concerns about the bill’s SALT, Medicaid, and IRA clean energy provisions. The next step for the bill is for it to pass in the Rules...

Medicare Physician Reimbursement

Included in the House Energy & Commerce (E&C) Committee’s section of the reconciliation bill are reforms to reimbursements under the Medicare Part B Physician Fee Schedule (PFS). Notably, the bill does not include temporary relief from the -2.93% conversion factor cut in effect for CY25. However, the bill does include long-term reforms to PFS...

Pharmacy Benefit Managers (PBMs)

Republicans on the House Energy & Commerce (E&C) Committee have included as part of their section of the reconciliation bill various reforms regarding PBMs. Specifically, those include (1) a ban on spread pricing in the Medicaid program, (2) a prohibition on PBM compensation being based on a drug’s list price in the Medicare Part D program (so...

Affordable Care Act (ACA) Subsidies

The House Ways & Means (W&M) Committee has released the legislative text covering its portion of Republicans’ reconciliation legislation. Notably, the bill text does not include an extension of the ACA enhanced subsidies (which will expire at the end of this calendar year). However, the bill – as well as the E&C bill – includes various...