Oz Still Demanding Greater Medicare Advantage Accountability
At a Better Medicare Alliance event Wednesday, Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz declared his support for Medicare Advantage (MA) but argued the plans could improve in several areas. Specifically cited were improper payments and prior authorization. Oz previously announced a voluntary plan agreement to streamline and limit prior authorizations as well as a new CMS program to conduct risk adjustment audits on 100% of MA contracts every payment year.
The latter initiative was hit with a major roadblock when a federal judge struck the rule governing how the agency would carry out such audits. CMS did not respond to a request for comment on whether it plans to repromulgate the audit rule and Oz stayed mum during the event but has implied he wants to continue the robust audit efforts.
Oz specifically called out the use of home health risk assessments and the coding inflation that occurs through them. A number of studies indicate that many diagnoses reported on these assessments never end up reported on encounters by doctors.
Overall, Oz said he believes MA is important to tackling mounting costs and wants to team up with the private sector on solutions instead of relying on government dictates.
I have a risk adjustment blog running tomorrow at the blog tab.
#medicareadvantage #overpayments #riskadjustment #radv
https://www.healthcaredive.com/news/oz-medicare-advantage-upcoding-reform-support/802879
Layoffs Could Be 10,000 But Are Temporarily Stalled
Office of Management and Budget (OMB) Director Russell Vought said that the Trump administration may lay off more than 10,000 federal workers permanently in light of the government shutdown.
A federal judge, however, has issued a temporary restraining order to halt layoffs at federal agencies for the time being, arguing Trump took advantage of the shutdown to execute the job cuts. She directed the administration not to act on reductions in force already conducted, to provide details on those noticed, and not to implement any further reductions. The order will be appealed and higher courts, especially the Supreme Court, could be more open to allowing such executive action.
As the shutdown continues, there are moderates in each party looking at ways to extend the Exchanges premium subsidy enhancements via a series of pare backs. The proposals could include minimum out-of-pocket premium payments, new income caps, and cutting off enhanced tax credits for new enrollees.
Meanwhile, fifteen Democratic state governors unveiled a new coalition to coordinate public health efforts given the erosion of public health agencies and a move away from science there. The Governors Public Health Alliance would be the largest alternative public health authority run by states, representing 129 million Americans. Two other alternatives already exist among states in the west and states in the northeast. Memberships in the other two overlap with the new alliance.
Additional articles: https://www.politico.com/news/2025/10/14/republicans-democrats-shutdown-obamacare-subsidies-00606480 and https://www.fiercehealthcare.com/regulatory/15-blue-governors-new-coalition-largest-alternative-public-health-coalition-yet and https://thehill.com/homenews/administration/5556978-trump-administration-federal-layoffs/?tbref=hp
#governmentshutdown #trump #congress #healthcare #coverage #layoffs #exchanges
Humana Plots Stars Comeback
After losing its 2025 Star appeal, Humana says it has a strategy to bounce back on Medicare Advantage (MA) Stars. The MA-dominant insurer says it plans to steer new members toward its top-scoring products and away from lower-performing ones. Humana says it is on track to achieve higher scores in Star Year 2027. Its financial plan assumed lower scores and revenue and that more than 90% of its products are profitable this year.
Humana was once the golden child of Stars, with 94% of is membership in 4 Star and greater plans in Star Year 2024. In Star Year 2025, that dropped to just 25% and will be 20% in Star Year 2026. In 2025, a Preferred Provider Organization (PPO) contract with 47% of its enrollment dropped below 4 Star and has yet to recover. So far, Humana has not split up the master contract.
(Article may require a subscription.)
#medicareadvantage #stars #quality #humana
https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-ratings-plan-growth
— Marc S. Ryan
