CMS to get ‘tougher’ on Medicare Advantage, official promises

CMS Deputy Administrator Jon Blum signaled regulators could increasingly crack down on bad actors in the MA program, which now covers more than half of Medicare seniors.

By Rebecca Pifer • Sept. 22, 2023

Federal agencies propose increase to No Surprises Act administrative fees

On Thursday, the HHS and other departments proposed a rule that would raise the independent dispute resolution process fees from $50 to $150. Last month, a federal court vacated a rate of $350.

By Susanna Vogel • Sept. 22, 2023

Explore the Trendline➔

Payer/Provider relationships

As M&A intensifies and companies embrace more holistic and value-based care models, partnerships have become more closely intertwined.

By Healthcare Dive staff

CMS requires 30 states to pause Medicaid disenrollments after systems error

Nearly 500,000 people will regain Medicaid or Children’s Health Insurance Program coverage after being improperly removed from the rolls during redeterminations, according to the HHS.

By Emily Olsen • Sept. 22, 2023

Cigna hit with second class action suit over claims automation software

The lawsuit was filed in Connecticut and seeks class action status to represent all consumers nationwide who had claims reviewed by PxDx.

By Rebecca Pifer • Sept. 20, 2023

Frustration over surprise billing implementation builds in House hearing

Bipartisan lawmakers joined together to voice concerns about the implementation of the No Surprises Act, which critics say has created barriers to care.

By Susanna Vogel • Sept. 20, 2023

Home health advocates raise alarm over payment cuts, access to care

A new payment model and reimbursement cuts are straining home health agencies, but more data may be needed to fully evaluate the model, advocates and researchers said during a Senate finance committee hearing.

By Emily Olsen • Sept. 20, 2023

PBMs, PhRMA trade blame over drug costs in House hearing

Pharmacy benefit manager lobby PCMA and drugmaker lobby PhRMA pointed fingers over problems in the prescription supply chain during the House committee's second PBM hearing on Tuesday.

By Rebecca Pifer • Sept. 19, 2023

Tennessee BCBS sued by former employees over COVID vaccine mandate

The new lawsuit alleges the nonprofit health plan violated employees' religious rights by not granting them an exemption to its inoculation requirement.

By Rebecca Pifer • Sept. 18, 2023

CMMI teases new behavioral, maternal health models launching this year

The timeline of the two upcoming models could be pushed back if Congress doesn’t come to a funding agreement and the government shuts down, CMMI head Liz Fowler said.

By Rebecca Pifer • Sept. 15, 2023

Majority of ground ambulance rides were out of network in 2022, report finds

Patients often have little choice of ambulance provider, and federal law doesn’t protect them from surprise bills from the rides.

By Emily Olsen • Sept. 14, 2023

BCBSA finds wide variety in medical cost by site

Researchers said their data supports site-neutral proposals to make care cost the same regardless of where it’s provided. Momentum is building in Congress around the policies, but they face fierce opposition from hospitals.

By Rebecca Pifer • Sept. 14, 2023

GoodRx, MedImpact partner on automatic drug discounts

The digital health company has notched its third partnership with a PBM in a bid to increase access to its drug discount coupons.

By Rebecca Pifer • Sept. 14, 2023

PBM reforms in Congress would have modest effect at best and backfire at worst, Brookings says

Congress is inching closer to pharmacy benefit manager reform with new legislation released last week. But even eliminating all PBM profits would barely move the needle on U.S. drug spending, according to a new report.

By Rebecca Pifer • Sept. 13, 2023

CVS CEO ‘optimistic’ payer will improve MA star ratings

At Morgan Stanley’s healthcare conference on Tuesday, Karen Lynch also called into question the $500 million in savings Blue Shield of California expects from kicking CVS’ pharmacy benefit manager to the curb.

By Rebecca Pifer • Sept. 13, 2023

Low-income seniors more likely to report fraudulent marketing from private Medicare plans

The Commonwealth Fund survey comes after regulators finalized a rule this spring aiming to cut back on deceptive and misleading advertising for Medicare Advantage plans after beneficiary complaints rose.

By Emily Olsen • Sept. 12, 2023

L.A. Care to pay $1.3M to settle potential HIPAA breach violations

The settlement comes after state regulators levied a $55 million fine against the health plan last year for alleged operational deficiencies, including failure to address a backlog of over 9,000 prior authorization requests.

By Sydney Halleman • Sept. 12, 2023

Employers expect health benefit costs to climb 5.4% in 2024

High inflation, labor shortages and industry consolidation contributed to the projected increase, according to a new survey of employers from consultancy Mercer.

By Brian T. Horowitz • Sept. 11, 2023

MA enrollment in rural areas nearly quadrupled since 2010, KFF finds

More rural seniors are turning to Medicare Advantage, but the plans can offer limited provider networks. That could prove an additional challenge for rural beneficiaries who already have to travel further distances for care.

By Emily Olsen • Sept. 8, 2023

CVS shuffles C-suite, appoints CFO as head of health services

Shawn Guertin will now helm the healthcare giant's suite of care delivery businesses, including Oak Street and Signify, as CVS undergoes a major corporate restructuring following flagging profits.

By Rebecca Pifer • Sept. 8, 2023

Astellas withdraws lawsuit challenging Medicare drug price program

Contrary to the drugmaker’s expectations, its top-selling cancer medicine Xtandi wasn’t picked as one of the first 10 drugs to face price negotiations.

By Ned Pagliarulo • Sept. 7, 2023

MA plans were overpaid $9.3B annually from 2017 to 2020, study finds

Favorable selection of healthier beneficiaries led to overpayments in counties with high Medicare Advantage penetration, but benchmark changes could mitigate the impact.

By Emily Olsen • Sept. 6, 2023

CMS creates all-payer funding opportunity for states

Regulators' latest effort to nudge the U.S. away from fee-for-service takes a page from how Maryland pays its hospitals.

By Rebecca Pifer • Sept. 6, 2023

Patients ‘steered’ toward health systems, more costly treatment after vertical consolidation, study finds

Consolidation between primary care physicians and large health systems led to increased costs per patient, according to a new study published in JAMA.

By Susanna Vogel • Sept. 5, 2023

Humana sues HHS over Medicare Advantage audits

The payer, which brings in the bulk of its revenue from Medicare, is fighting a rule finalized earlier this year to claw back overpayments in the increasingly popular MA program.

By Rebecca Pifer • Sept. 5, 2023

‘We’re in the 1999 of the internet era’: a16z’s Julie Yoo on fintech’s potential and the digital health market

Yoo, who leads health tech investment at venture capital firm Andreessen Horowitz, outlined her fintech investment thesis and why the healthcare industry is at an inflection point for adoption.

By Rebecca Pifer • Aug. 31, 2023