Another Stars Lawsuit — This Time From Alignment
High-performing MA plan Alignment Healthcare has joined the lawsuit fray on the Clover decision. Alignment has the same argument as Scan. Both indicated CMS erred by including ten measures in the CMS Recalculation scenario when a judge ruled these measures did not go through the correct regulatory vetting process.
Alignment says three of its contracts currently rated 4.0 should be at 4.5, netting an additional $50 million.
If you are adding up the numbers from lawsuits, here is the total:
–Clover = $120M
–Elevance Health = $115M
–Scan = $125M
–Alignment = $50M
TOTAL = $410M
I had earlier estimated the total costs to be over $1 billion.
Alignment lawsuit: https://lnkd.in/entBMgHn
#cms #stars #quality #medicareadvantage
Plans Oppose No Surprises Bill
A health plan group has launched a campaign challenging a congressional bill that would implement even more friendly provider elements in the No Surprises Act (NSA). The bill would add new fines for employers or insurers for delays in final payment adjustments but fails to reform the unlevel playing field which sees providers winning the vast majority of disputes with awards well above pre-NSA levels.
In other news, a federal judge dismissed a lawsuit from Blue Cross Blue Shield of Georgia against medical billing company HaloMD and two physician groups. The plan said they conspired to defraud the insurer through the No Surprises Act’s arbitration process.
Additional article: https://www.beckerspayer.com/legal/judge-dismisses-another-no-surprises-lawsuit-from-elevance/
#nsa #nosurprisesact #transparency #providers #healthplans
OBBBA Having State Budget Impacts
States are beginning to see fiscal woes due to the fallout from the One Big Beautiful Bill Act (OBBBA), which will reduce Medicaid spending by about $1 trillion over ten years. New work requirement mandates begin to hit in January. After that, restrictions on provider taxes and state directed payments begin to take effect.
States are looking at raising taxes on insurers and employers, along with cutting Medicaid services.
(Article may require a subscription.)
#obbba #medicaid #workrequirements
https://www.modernhealthcare.com/politics-regulation/mh-trump-tax-law-medicaid-states/
Employers, Plans Sour On GLP-1s
With emerging but not overwhelming evidence that GLP-1s reduce overall health costs, employers, health plans, and pharmacy benefits managers (PBMs) are raising doubts about the ability to justify costs for the drugs when it comes to obesity. GLP-1s are highly adopted for disease states such as diabetes and heart disease.
#glp1s #weightlossdrugs #drugpricing
OIG Touts Fraud Recoveries
The Department of Health and Human Services Office of Inspector General (HHS OIG) generated $5.56 billion in expected fraud recoveries and projected savings over the six-month period from October 2025 to March 2026. OIG’s recoveries also barred just over 1,200 individuals and companies from federal programs.
#fwa #hhs #oig #healthcare
https://thehill.com/policy/healthcare/5966489-hhs-oig-crackdown-fraud/
— Marc S. Ryan
