Could Bipartisan Healthcare Reforms Be In The Making?
Senate Republicans say they are working on a bipartisan healthcare package to lower drug and health insurance costs. Democrats say they have not been brought into the process and are skeptical.
Sen. Bill Cassidy, R-LA, who leads the HELP Committee, is leading the talks, with pharmacy benefit managers reform and stopping upcoding practices in the Medicare Advantage (MA) risk adjustment program at the top of the list of reforms. Further, a group of Republican senators, including Lisa Murkowski of Alaska, are pushing to extend the expiring Exchange enhanced premium subsidies.
It appears that even conservative Senate Finance Chair Michael D. Crapo, R-Idaho, who chairs the Senate Finance Committee, is involved.
#healthcare #riskadjustment #medicareadvanage #pbms #drugpricing
https://rollcall.com/2025/07/23/republicans-plan-bipartisan-health-package-as-democrats-demur
Prominent Insurer Executives Cover Major Issues
A Modern Healthcare webinar had a number of prominent Medicare Advantage (MA) executives outlining concerns regarding recent announcements.
First, they distanced themselves from the practices of the largest health plans in the nation. Second, they criticized the 100% risk adjustment audits as a huge administrative burden and dubious methods around sampling and extrapolation of penalties. They backed multi-year enrollment, more regulatory flexibility, and a requirement that providers must accept MA at 100% Medicare rates if they are in the traditional program. They also feel the star program needs to be reformed.
In other news, healthcare lobby AHIP issued a blog that does a great job of showing the positives of MA for seniors as well as the program. It is here: https://www.ahip.org/news/articles/the-facts-on-ma-delivering-greater-value-for-seniors-taxpayers-than-fee-for-service-medicare . The blog shows the savings for members, better quality outcomes, and the fact that MA serves greater numbers of low income and those of color.
(Some articles may require a subscription.)
#medicareadvantage #riskadjustment #ahip
https://www.modernhealthcare.com/insurance/mh-sanford-alignment-scan-group-medicare-advantage
United Admits It Is Under Investigation
UnitedHealth Group formally acknowledged it is being investigated by the federal government into its Medicare Advantage (MA) risk adjustment coding practices. Sources say investigators have been digging into how the insurer may have been deploying clinicians to increase diagnoses that may have led to overpayments.
Additional articles: https://www.fiercehealthcare.com/payers/wsj-report-doj-interviewing-former-employees-about-medicare-billing-practices-unitedhealth and https://www.modernhealthcare.com/insurance/mh-unitedhealth-group-doj-medicare-probes/ and https://www.beckerspayer.com/legal/unitedhealth-complying-with-doj-investigation-5-things-to-know/
(Some articles may require a subscription.)
#riskadjustment #doj #hhs #cms #unitedhealthcare
— Marc S. Ryan
