New Analysis on MA Overpayment
I have argued that a small subset of big plans have given all of Medicare Advantage (MA) a bad name by suspect or fraudulent risk adjustment practices that give them major overpayments. A number of studies have singled out this small group of major plans. Now, the Alliance of Community Health Plans (ACHP), a group that represents local and regional nonprofit payers, has come out with a study building on these earlier findings.
ACHP says that UnitedHealthcare, the biggest MA insurer, collected up to $785 more per beneficiary than local nonprofit plans in 2023, costing Medicare more than $6 billion in excess payments that year. Humana, the second-biggest MA payer, collected $423 more per beneficiary that year than if those members were in ACHP member plans, costing Medicare an additional $4 billion. UnitedHealthcare’s average risk scores were 36.2% higher and Humana’s were 19.2% higher than nonprofit health plan members of ACHP. Earlier studies show annual overpayments for United were $14 billion in 2021.
ACHP wants a new system of accounting for members’ health needs based on patient demographics, such as age, sex, disability status, and on a small list of substantiated health conditions.
Additional articles: https://www.healthcaredive.com/news/unitedhealthcare-humana-medicare-advantage-risk-adjustment-gaming-achp/759120/ and https://www.fiercehealthcare.com/payers/achp-unveils-plan-streamline-ma-risk-adjustment-combat-upcoding-gamesmanship
#medicareadvantage #fwa #riskadjustment #radv #overpayments
New CBO Analysis Shows Improper Enrollments
Republicans have touted the need for reform in the Exchanges due to what they believe are improper enrollments. The Paragon Health Institute and the Centers for Medicare and Medicaid Services (CMS) both recently published data on a growing number of people with no claims activity. Now, the Congressional Budget Office (CBO) is indicating that 2.3 million individuals received premium tax credits improperly by misstating their income. That grew from 1.3 million people who did the same in 2023, according to the CBO.
#fwa #enrollment #exchanges
Drug Makers Campaign For 340B Reform
The brand drug lobby, the Pharmaceutical Research and Manufacturers of America, launched an advertisement campaign that takes aim at the 340B Drug Pricing Program. The Trump administration announced a voluntary pilot to reform the 340B program, where drug makers would issue retrospective rebates as opposed to upfront discounts to qualifying safety net providers.
The campaign seeks to safeguard the progress on reform by pointing out the major abuse of the program by major hospitals. The advertising campaign describes the subsidies as “a hidden tax on patients, employers and taxpayers.” A number of studies shows that the discounts are not passed through to low-income residents as intended and that prices at qualifying hospitals are often more than at non-qualifying ones.
Additional article: https://www.modernhealthcare.com/providers/mh-phrma-340b-drug-pricing-program-ad/
(Some articles may require a subscription.)
#340b #drugpricing #hospitals
SCAN To Expand In MA
SCAN Health Plan announced that it intends to expand its Medicare Advantage (MA) offerings to Washington. It also plans to grow in California and Texas.
#scan #medicareadvantage
https://www.fiercehealthcare.com/payers/scan-health-plan-expand-ma-footprint-washington-2026
United’s Gold Card Program Grows
UnitedHealthcare’s prior authorization (PA) gold card program has seen an increase in the number of qualifying provider groups in 2025 of more than 40%. The program is part of United’s efforts to reduce the cost and impact of PA. Health plans voluntarily agreed to PA reform earlier this year.
#priorauthorization #healthplans #unitedhealthcare
https://www.beckerspayer.com/payer/unitedhealthcare-grows-gold-card-program
Information Blocking Enforcement
The Department of Health and Human Services’ (HHS) investigation unit and health IT offices will step up enforcement of information blocking. Such data stoppage is barred under an interoperability rule put in place several years ago.
#interoperability #healthcare #hhs
— Marc S. Ryan
