Are you a Provider-group or ACO that has a full-risk Medicare-Advantage (MA) contract with a Medicare-Advantage Organization such as Humana?

Are your capitation or value-based payments less than you expected? And even if you believe you are satisfied with your capitation payments – are you sure they have been correctly calculated by your Medicare-Advantage Organization?

Are your CMS Hierarchical Condition Category (HCC) risk scores lower than other providers’?  Lower than the average risk score in your market?  Chances are that it’s not you – It’s them! The name of the game when dealing with Medicare-Advantage Organizations (“MAOs”) is not “trust, but verify” – but “don’t trust, but do verify,” as MAOs have every incentive to nickel and dime their providers.

Mile High Healthcare Consulting and a national boutique healthcare law firm, Frier Levitt, can help recover the missing revenue you are entitled to under your MAO contracts and applicable law—revenue intended to compensate your group for providing comprehensive health care to your patients!

The keys to protecting our full-risk contracted Provider group clients lies in understanding both the contracts and law, following the data trail and then fighting for justice.

It is an industry norm that MAOs provide first tier delegated entities, such as risk-bearing Provider groups and ACOs, with extracts from the MAOs’ native MMR, MOR, and accepted RAPS files. However, evidence suggests that not all MAOs do so. In a currently filed lawsuit (in which Mile High Healthcare Consulting is Plaintiff, a link to the Complaint for which is here) against Humana and certain Provider groups, for example, it is alleged that Humana – which controls a very substantial percentage of the total MA market share – only provides its downstream Provider groups with its own versions of CMS data extracts (RERAP, REENCNTR, RECLMDSP, RECLMEXP, REHCF/REHCG, REMMR, RECAP, and REMORTY) that it creates.  As alleged, these non-standard data extracts are incomplete, making it impossible for Providers to accurately determine what has or has not been accepted by Humana’s submissions to CMS, or, for that matter, what has or what has not been submitted by Humana to CMS.  If these allegations prove to be true, it would mean that it would be impossible to determine the impact that a Humana-contracted physician group’s data may have on patient risk scores, making it equally difficult to determine the data’s impact on the value of the group’s earned shared savings or capitation payments.  Our experience with MAOs strongly suggests that this lack of data transparency is designed to frustrate Providers’ ability to verify the true value of shared savings earned under MAO-contracts so that, ultimately, they may avoid making full payment to those Providers.

Mile High Healthcare Consulting, working in conjunction with the law firm of Frier Levitt and actuarial consultants, has developed proprietary data analytics processes to identify HCCs for which the Provider group has not been paid.  Importantly, in addition to analyzing data under in-force value-based contracts, Mile High and Frier Levitt have also teamed up to help negotiate future value-based payment or capitation contracts that can provide specific contractual protections designed to preempt an MAOs ability to play games with, or make errors in analyzing, the submitted claims or encounter data, that can reduce the Providers’ value-based or capitation payments. Mile High has developed proprietary methods over the course of thousands of hours of data analysis and coding.  Our processes help delegated physician groups track payments by analyzing data submitted to your MAO and/or CMS.  For prior payment years with finalized CMS payments to your MAO, we are able to calculate and confirm the risk scores and dollars that it was paid and, based on the results of this analysis, we can then evaluate whether appropriate payments did or did not flow “downhill” from CMS to your MAO and, ultimately, to the delegated Provider group or ACO.

Mile High Healthcare Consulting and Frier Levitt will perform these services on a modified contingency fee basis. After charging an initial data acquisition fee, we will provide you with a high-level report that will show to what extent an HCC discrepancy exists. Should you decide to move forward, the remainder of the engagement will be on a contingency basis with our team getting a share of the unpaid revenue we identify. Beyond the initial fee, we will not get paid until you recover what you are owed.

Are you ready to start?

Have a copy of your contract between your Provider group and your MAO available so that we can ascertain the audit rights and payment terms contained in the executed agreement.

For legal questions regarding MAO contracts, contact Frier Levitt attorney Jason N. Silberberg, Esq., at or call 973.618.1660