Elevance Gets A Reprieve
Elevance Health avoided sanctions for now, including an enrollment and marketing freeze, after the Centers for Medicare and Medicaid Services (CMS) granted the Medicare Advantage (MA) plan an extension to make up for incorrect risk adjustment data reporting. Elevance has until May 30 to remediate the issues.
At the same time, a bipartisan group of senators is urging CMS to work with Congress to crack down on overpayments in MA.
Further, a lawsuit alleging Elevance Health’s Carelon Behavioral Health misled beneficiaries about the scope of its provider network was allowed to move forward by a judge.
Additional article: https://www.healthcaredive.com/news/elevance-sidesteps-medicare-advantage-sanctions-cms/816324/ and https://www.fiercehealthcare.com/payers/blue-cross-plan-accused-perpetrated-fraud-ghost-network-class-action-lawsuit and https://www.modernhealthcare.com/insurance/mh-carelon-behavorial-ghost-network-lawsuit-elevance/
(Some articles may require a subscription.)
#medicareadvantage #riskadjustment #overpayments #elevancehealth
Hospitals DSH It Out To HHS
Over 130 hospitals are suing the Department of Health and Human Services (HHS) over a 2024 rule involving changes to how payments to hospitals treating a large proportion of Medicare patients are calculated. The rule retroactively adjusted how Medicare Advantage (MA) patients treated by hospitals are counted by the Centers for Medicare & Medicaid Services (CMS) when determining the payment’s Medicaid fraction and the Supplemental Security Income (SSI) fraction. The two percentages are combined to calculate a hospital’s disproportionate patient percentage. This determines whether the hospital qualifies for a Disproportionate Share Hospital (DSH) payment and the amount.
In other news, hospital associations want Congress to refine payment criteria for long-term care hospitals (LTCH).
Additional article: https://www.fiercehealthcare.com/providers/131-hospitals-sue-hhs-over-2023-rule-disproportionate-share-hospital-calculation
#hospitals #uncompensatedcare #dsh
States Deal With Medicaid Shortfalls
While federal law will reduce Medicaid provider taxes in the future, some states are now passing temporary increases to deal with Medicaid budget shortfalls. Iowa just passed a retroactive tax on health insurance companies.
Also, a Kaiser Health News article discusses how community health centers are bracing for the fallout from the One Big Beautiful Bill’s Medicaid cuts.
Additional article: https://www.modernhealthcare.com/politics-regulation/mh-nebraska-medicaid-work-requirements-health-centers/
(Articles may require a subscription.)
#medicaid #providertaxes #states #healthplans #providers #fqhcs
https://www.modernhealthcare.com/politics-regulation/mh-medicaid-iowa-health-insurance-tax
— Marc S. Ryan
