Payer: Page 26
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CMS recalculates Medicare Advantage star ratings in major win for insurers
The redo comes after regulators lost two court cases over the methodology used to determine 2024’s quality ratings and should result in hundreds of millions of dollars in additional bonuses to plans.
By Rebecca Pifer Parduhn • June 14, 2024 -
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Cardiovascular conditions now the second-highest reimbursement category, Sun Life says
Cost of cardiovascular conditions is up 33% — “higher than we would expect given medical inflation,” the insurance provider said.
By Emilie Shumway • June 13, 2024 -
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National health spending reached $4.8T last year, CMS actuaries estimate
More Americans had insurance in 2023 than at any other time in the nation’s history, spurring medical utilization and accelerating healthcare spending faster than growth in the overall economy, according to government projections.
By Rebecca Pifer Parduhn • June 12, 2024 -
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MACPAC wants Congress to force states to disclose Medicaid financing streams
The influential advisory group has been lobbying the federal government to collect more detailed information on how states loop providers into funding Medicaid for almost a decade.
By Rebecca Pifer Parduhn • June 12, 2024 -
Permission granted by Elevance Health
Elevance wins star ratings lawsuit (sort of)
Friday’s district court ruling is the latest suggesting the CMS might have to recalculate every MA plan’s star rating score due to an administrative oversight.
By Rebecca Pifer Parduhn • June 11, 2024 -
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Sponsored by PointClickCareLeveraging technology to achieve balance in healthcare
Leveraging technology is crucial for healthcare to enhance care, automate tasks and optimize outcomes.
By B.J. Boyle, Chief Product Officer, PointClickCare • June 10, 2024 -
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Sponsored by Veradigm3 ways value-based care is transforming American healthcare
This transition to value-based care is transforming the healthcare system. Medical practices can expect many benefits from this transformation—but only after fully embracing the shift.
By Amanda Cohen, MPH • June 10, 2024 -
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Affordable Care Act insurers could be on the hook for $1.1B in rebates this year
Rebates this year could cross the billion-dollar mark for the fifth time in the past decade, according to an analysis from the KFF.
By Rebecca Pifer Parduhn • June 7, 2024 -
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Deep DiveHumana and CVS are downsizing their Medicare Advantage plans for 2025. Which insurers could benefit?
Hundreds of thousands of seniors could switch plans during next year’s open enrollment, depending on how drastically the MA market giants slash benefits in an attempt to improve profits.
By Rebecca Pifer Parduhn • Updated June 10, 2024 -
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Scan Health Plan wins Medicare Advantage star ratings lawsuit
The insurer argued the CMS didn’t follow its stated methodology for calculating quality scores, causing its rating to drop and risking millions of dollars in payments.
By Emily Olsen • June 4, 2024 -
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Medicare Advantage sales middleman sues HHS over rule capping broker compensation
AmeriLife’s suit joins at least two others from MA sales groups seeking revisions to the rule for threatening their business model. It also comes with a clock, given a looming deadline for marketing contract negotiations.
By Rebecca Pifer Parduhn • June 3, 2024 -
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Move over, Medicare Advantage — UnitedHealth, Centene flag higher Medicaid utilization concerns
Worries about higher-than-expected medical spending have reached Medicaid, as redeterminations spark turbulence in the program.
By Rebecca Pifer Parduhn • May 30, 2024 -
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Minnesota’s Medicaid program to block for-profit insurers from participation
The ban initially only affects UnitedHealthcare, which is the sole for-profit managed care organization with a Medicaid contract in the state.
By Rebecca Pifer Parduhn • May 29, 2024 -
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Express Scripts’ new partnership is an olive branch to independent pharmacies
Cigna’s massive pharmacy benefit manager has unveiled a new collaboration with a network of independent pharmacies at a time of rising tension between PBMs and the pharmacies they pay.
By Rebecca Pifer Parduhn • May 23, 2024 -
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House committee takes aim at healthcare consolidation, eyes site-neutral payments
Equalizing Medicare payment between sites of service to cut down on provider consolidation is a “no brainer,” one witness testified during the hearing.
By Rebecca Pifer Parduhn • May 23, 2024 -
Courtesy of Tandem Diabetes Care
Medicare adviser sets recommendations for diabetes device evidence
The panel found time in range was an “extremely important” metric, but members were divided on whether quality of life measures should influence coverage.
By Elise Reuter • May 22, 2024 -
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Latest 340B ruling delivers blow to providers
Drugmakers are allowed to impose conditions on which pharmacies they dispense discounted drugs to in the 340B program, according to an appellate court.
By Sydney Halleman • May 22, 2024 -
Courtesy of UnitedHealth Group
UnitedHealth’s Optum Rx unveils new drug pricing model
Major pharmacy benefit managers are rolling out a flurry of ostensibly transparent and cost-effective models to retain clients and placate scrutiny over their role in rising drug costs.
By Rebecca Pifer Parduhn • May 21, 2024 -
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Senate Finance Committee tackles Medicare physician pay reform
On Friday, the committee released a white paper proposing Medicare adjust doctor reimbursement to account for inflation, a key goal for physician lobbies.
By Rebecca Pifer Parduhn • May 20, 2024 -
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Kansas jilts CVS in new Medicaid contract awards
Kansas kicked CVS to the curb in favor of an Elevance plan, while awarding contracts to incumbents UnitedHealth and Centene. The contracts are worth roughly $4 billion annually.
By Rebecca Pifer Parduhn • May 15, 2024 -
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Hospitals charged employers and insurers 254% more than Medicare in 2022: study
Hospitals with larger market shares were among the worst offenders, the Rand Corporation found.
By Susanna Vogel • May 14, 2024 -
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Humana CEO Bruce Broussard to depart July 1
At that time, current Chief Operating Officer Jim Rechtin will take the reins of the health insurer, which is struggling with challenges in Medicare Advantage.
By Rebecca Pifer Parduhn • May 14, 2024 -
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Deep DiveMedicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1
All major payers saw elevated utilization but only an unprepared few struggled with the trend, the Change Healthcare cyberattack caused minimal financial fallout and a new D-SNP rule opens the door to a Medicare growth opportunity.
By Rebecca Pifer Parduhn • May 13, 2024 -
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CHS sues MultiPlan for allegedly colluding to lower provider reimbursement
It’s the third lawsuit filed against MultiPlan by a health system in under a year.
By Rebecca Pifer Parduhn • May 10, 2024 -
Alex Wong via Getty Images
CMS proposes mandatory kidney care model with financial risk for hospitals
The model, if finalized, will test whether putting hospitals on the hook for kidney transplant access and quality might improve the nation’s shoddy system of organ procurement and transplantation.
By Rebecca Pifer Parduhn • May 9, 2024
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