1. The DOJ is investigating Medicare Advantage Plans
The Federal False Claims Act (FCA) is a law that prohibits knowingly submitting false claims for payment to government healthcare programs like Medicare and Medicaid and Medicare Advantage Plans. The definition of “Knowingly” includes deliberate ignorance or reckless disregard of the truth.
The DOJ is responsible for overseeing the act, and violators are liable for three times payments plus mandatory penalties.
In 2025, the DOJ recovered 6.8 BILLION from sectors like Medicare Advantage and others.
While opportunities for billing Medicare Advantage plans have dwindled to mostly self-funded plans for retirees known as Employer Group Waiver Plans (EGWPs), if you’ve billed a Medicare Advantage plan in the last 6 years you could be on the radar.
Should you be worried?
So do you have anything to worry about? If your documentation is relatively good indicating the patient had chronic low back pain, NOPE. HOWEVER, I have heard of offices, BILLING for a chronic low back pain code, while treating the patient for primarily other things. IF that is the case, then yes you could be under the radar.
2. Carriers are actively recouping previous payment for Patient’s with Medicare as Primary
We are seeing take backs for claims processed and paid a year or more ago. In these cases, the patient had Medicare as a primary and a stand alone secondary plan. Offices billed with the -GY modifier, indicating Medicare will NOT pay and as such the office received payment.
NOW, carriers are going back, sometimes years and demanding payment for NOT receiving a Medicare EOB. In some cases they are INSISTING that a Medicare EOB MUST be provided, not understanding, (or MAYBE understanding) that an Acupuncturist cannot enroll in the system and therefore cannot get a Medicare EOB.
Why is this happening?
On January 26th, the federal government is restricting growth for 2027 for all carriers offering Medicare Advantage plans and the carrier’s stock began a decent. Humana dropped more than 20%, UHC dropped 19% while Elevance/Anthem dropped 13%. These are all publicly held companies and they are taking a bath. If you need to increase revenue and you can’t increase prices what do you do? You CLAW back money. The first wave of audits and requests were from the federal government suing the carriers and as such the carriers had to claw back.
Now, their future is decreased reimbursement and tanking stock prices. The only thing left for them to do is to drop lines of business, (like some carriers started doing last year) and putting in models to bring in money.
I KNOW most providers don’t knowingly or willingly commit fraud. But these guys aren’t listening to excuses or offering any considerations. They are actively and seriously looking to take back money, lots of money, and if they have to get it from providers, they certainly will.