Emerging Trends in Managed Care Enforcement: The “Advantage” of Strong Governance and Compliance

Medicare Advantage enforcement has evolved from a scattered set of whistleblower actions into a coherent and predictable pattern — and that consistency is exactly what should concern compliance officers and defense counsel alike. At the American Health Law Association’s (AHLA) Annual Meeting, Christi Grimm, former Inspector General for the U.S. Department of Health and Human Services, and Giselle Joffre, Partner at Arnold & Porter and former federal prosecutor, detailed how Medicare Advantage oversight has evolved and discussed what recent U.S. Department of Justice (DOJ) resolutions reveal about the future of enforcement.

Grimm began by tracing Medicare Advantage enforcement back to its origins. Grimm noted that the previously scattered enforcement landscape was transformed as usable encounter data increasingly became available. Increased access to such data served as the inflection point that allowed regulators to systematically compare submitted diagnoses against actual care, revealing a troubling pattern of serious diagnoses with no corresponding treatment across multiple large plans. She also explained how compliance programs often broke down, noting that risk adjustment was too often treated as a coding function rather than a governed system, producing structural failures rather than merely technical ones.

Joffre then turned to the future of enforcement, highlighting the reverse false claim theory that now anchors much of this enforcement landscape. In case after case, the alleged wrongdoing is not merely submitting an unsupported diagnosis; it is often knowing about it — including through an organization’s own internal audits — and failing to delete the code and repay Centers for Medicare & Medicaid Services. Joffre also highlighted the differences in Medicare Advantage investigations and other types of investigations. Medicare Advantage investigations are particularly data-intensive, raise issues about the provider/plan relationship, and sometimes venture into questions concerning clinical judgment. As a result, statistical analysts, coding experts, and health care provider experts are helpful to bolster a plan’s defense strategy.

Where does Medicare Advantage enforcement go from here? The panel’s closing view was candid: Medicare Advantage enforcement is accelerating, not leveling off. Expect AI and data analytics to play a far larger role in surfacing new cases, as regulators connect risk scores, encounter data, and denial patterns at a scale no manual audit ever could. Expect Medicare Advantage to remain a top priority for DOJ, not a passing enforcement trend. And expect closer coordination between state and federal enforcement, as Medicaid managed care programs confront the same risk adjustment dynamics already playing out at the federal level. For health plans, providers, and the vendors who serve them, the takeaway is clear: documentation alone is no longer enough. Regulators are increasingly focused on whether companies’ compliance systems actually work in practice.

If you have questions about navigating this enforcement environment, reach out to the author or any member of our team.

© Arnold & Porter Kaye Scholer LLP 2026 All Rights Reserved. This Blog post is intended to be a general summary of the law and does not constitute legal advice. You should consult with counsel to determine applicable legal requirements in a specific fact situation.