Understanding the Impact of the D.C. Circuit’s Decision on the Medicare Advantage Overpayment Rule
This Briefing is brought to you by AHLA’s Payers, Plans, and Managed Care Practice Group.
- October 14, 2021
- Samantha Groden , Dentons US LLP
- Christopher Janney , Dentons US LLP
- Margo Smith , Dentons US LLP
- Janice Ziegler , Dentons US LLP
In 2014, the Centers for Medicare & Medicaid Services (CMS) promulgated a rule implementing the statutory overpayment report-and-return obligation imposed on Medicare Advantage (MA) plan sponsors by the Affordable Care Act (Overpayment Rule or Rule). UnitedHealthcare Insurance Company and other MA organizations (MAOs) under the umbrella of UnitedHealth Group Incorporated (collectively, United) successfully challenged the Overpayment Rule before the U.S. District Court for the District of Columbia. According to the district court’s 2018 decision, the Overpayment Rule (1) violated provisions in the Medicare statute setting forth the MA reimbursement risk-adjustment model, (2) was arbitrary and capricious in violation of the Administrative Procedure Act (APA), and (3) established an impermissible standard for determining if and when an overpayment has been “identified.”
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