By David Talby – Hierarchical Condition Category (HCC) coding supports risk scores that drive Medicare Advantage and other value-based payments. With more than half of Medicare beneficiaries now enrolled in Medicare Advantage for 2025 (that equates to roughly 35.7 million people), precision in coding directly affects financial performance and compliance.
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By Lauren Sausser & Darius Tahir – Taking a page from the private insurance industry’s playbook, the Trump administration will launch a program next year to find out how much money an artificial intelligence algorithm could save the federal government by denying care to Medicare patients.
By Deepan Vashi – Rebranding of the Health Equity Index reward brings new opportunities and challenges to Star ratings program. The name change reflects the agency’s “goal of ensuring exceptional care for all enrollees,” according to the CMS April 2025 capitation rate announcement.
By Marge Ciancetta – Among the most impactful changes released by CMS each year in the Medicare Advantage and Part D Final Rule are adjustments to the Star Ratings program. As a result of the most recently finalized changes, CMS projects a 0.69% decline in overall quality bonus payments for 2026.
By Arun Hampapur PhD – The U.S. healthcare industry is once again in the spotlight—this time, with the scrutiny on UnitedHealth. The Department of Justice has launched a civil fraud investigation into UnitedHealth Group, which highlights the ethical challenges and complexities around risk adjustment in Medicare Advantage.
HHS Secretary Kennedy and CMS Administrator Oz press conference on securing industry pledges to fix the broken Prior Authorization System. They met with insurance leaders of nearly 80% of covered Americans.
By Arielle Zionts – Rural hospital leaders are questioning whether they can continue to afford to do business with Medicare Advantage companies, and some say the only way to maintain services and protect patients is to end their contracts with the private insurers.
By Courtney Breece – The Medicare landscape is poised for significant changes with the release of proposed rules from the CMS in November, set to impact contract year 2026, aimimg to reshape key elements of Medicare Advantage, Medicare Prescription Drug Programs, and other Medicare services.
By Cynthia Henry – As the healthcare industry adapts to economic and regulatory changes, Medicare Advantage stands out as a cost-effective model consistently delivering value to beneficiaries. Compared to traditional fee-for-service Medicare, MA excels in financial efficiency and quality outcomes, making it a resilient choice for enrollees and a strategic asset for payers.