Cigna pays $172M to settle MA upcoding allegations

The agreement settles a whistleblower lawsuit against Cigna that the Department of Justice joined last year, and requires the payer to undergo annual auditing from an independent entity.

By Rebecca Pifer Parduhn • Oct. 2, 2023

CMMI increased federal spending by $5.4B during its first decade, report finds

The Congressional Budget Office report estimated the Center for Medicare and Medicaid Innovation, which was created in part to reduce spending, will increase net federal spending by $1.3 billion from 2021 through 2030.

By Emily Olsen • Sept. 29, 2023

Congressional Democrats open investigation into Medicaid MCOs over claims denials

Sen. Ron Wyden, D-Ore., and Rep. Frank Pallone, D-N.J., sent letters requesting information on coverage denials to seven payers, including UnitedHealthcare, Aetna and Centene.

By Rebecca Pifer Parduhn • Sept. 29, 2023

CVS hit with lawsuit from independent pharmacy over fees

A small Iowa pharmacy is accusing CVS Caremark of forcing independent pharmacies to sign one-sided contracts in order to stay in its network and continue dispensing drugs for its millions of covered lives.

By Rebecca Pifer Parduhn • Sept. 28, 2023

MA premiums increase slightly for 2024

CVS, UnitedHealth and Humana expanded their MA footprints 13%, 4% and 2% respectively for next year, according to an analyst analysis of the CMS data.

By Rebecca Pifer Parduhn • Sept. 27, 2023

Centene lays off 3% of workforce

The insurer has been struggling with headwinds from Medicaid redeterminations and MA star ratings. The layoffs follow similar workforce reductions at CVS Health earlier this summer.

By Rebecca Pifer Parduhn • Sept. 27, 2023

Cano sells Texas, Nevada centers to Humana subsidiary for $67M

The divestiture to Humana’s CenterWell Senior Primary Care business comes after Cano this summer said it was exploring a potential sale amid its worsening liquidity position.

By Rebecca Pifer Parduhn • Sept. 26, 2023

Elevance, BCBSLA pause $2.5B merger amid regulatory scrutiny

The health insurers originally expected their merger to close before the end of 2023, but have hit snags receiving the regulatory green light in Louisiana.

By Rebecca Pifer Parduhn • Sept. 26, 2023

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

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 Parduhn • 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

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

By Rebecca Pifer Parduhn • 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 Parduhn • 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 Parduhn • 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 Parduhn • 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 Parduhn • 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 Parduhn • 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 Parduhn • 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 Parduhn • 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