https://www.beckerspayer.com/legal/elevance-pays-cms-342m-amid-medicare-
Elevance Health paid CMS $342 million following a Medicare Advantage sanction notice alleging the insurer did not properly address overpayments for years.
June 22 filings in a New York federal court included an email from an Elevance vice president to CMS, confirming the payment was a “remittance of the total overpayment amount” related to the Risk Adjustment Overpayment Reporting module. Elevance conducted the wire transfer May 27, and CMS confirmed receipt the next day.
On May 29, a separate CMS letter informed Elevance that it had received the company’s attestation, but it did not specify the payment amount at the time. That step, along with initial submissions to the appropriate electronic systems, temporarily staved off intermediate sanctions. However, CMS said the insurer has until the end of June and July to complete further tasks — such as resolving issues across other risk-adjustment modules and addressing additional overpayment issues — before sanctions kick in.
The most recent filings also included a June 22 letter from the U.S. attorney’s office to the judge, challenging Elevance’s desire for additional discovery regarding the sanction notice.
“To the extent Anthem [now Elevance] wishes to challenge CMS’ administrative action, this is not the appropriate forum to do so,” the letter said.
CMS told Elevance in February that it would impose sanctions affecting MA prescription dr-g plan enrollment and communications due to a lack of compliance with risk-adjustment data submission requirements, interfering with the return of overpayments.
Elevance CFO Mark Kaye previously said the company had set aside $935 million to address the dispute. As of February, Elevance had about 2 million MA members.
This case is not the only source of tension between Elevance and the federal government right now. A Justice Department lawsuit first filed in 2020 alleges False Claims Act violations.
“Elevance Health continues to engage in constructive dialogue with the Centers for Medicare & Medicaid Services,” an Elevance spokesperson told Becker’s June 26. “We remain optimistic that a resolution can be reached and value our longstanding relationship with CMS.”
CMS said, if any sanctions take effect, current MA beneficiaries will continue to access their coverage and benefits as usual, since the sanctions would only apply to new enrollments and communications.
“CMS is committed to ensuring accurate Medicare Advantage (MA) payments, compliance with federal requirements and the protection of taxpayer dollars. Accurate and timely submission of MA risk adjustment data is essential to ensure Medicare pays appropriately for the beneficiaries they serve,” CMS told Becker’s in a June 29 statement.