Marc Ryan

Aetna Settles MA Risk Adjustment Case Aetna will pay $117.7 million to resolve False Claims Act allegations that it overbilled the Medicare program. The agreement settles claims related to past risk adjustment submissions in Medicare Advantage (MA). The Department of Justice said some diagnostic codes were not fully supported but were still submitted to secure higher payouts. Aetna also failed to withdraw some inaccurate diagnoses. Additional articles: https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-upcoding-claims/ and https://www.beckerspayer.com/payer/medicare-advantage/aetna-to-pay-118m-to-resolve-medicare-advantage-upcoding-allegations/ (Some articles may require a subscription.) #medicareadvantage #riskadjustment #overpayments #fwa https://www.fiercehealthcare.com/payers/aetna-pay-1177m-settle-medicare-advantage-false-claims-case-doj CMS Goes Hollywood On Fraud The Centers for Medicare and Medicaid Services (CMS) has gone Hollywood with glitzy ads bringing attention to fraud, waste, and abuse (FWA). The Trump administration has had some success. The Department of Justice reported a record $6.8 billion in settlements and judgments under the False Claims Act in the fiscal year that ended Sept. 30, 2025. #fwa #cms https://www.medpagetoday.com/special-reports/exclusives/120256 Researchers Track MA Diversity A

Oz Says Exchanges Have Major Fraud Problem Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz claimed in his strongest terms yet that he believes major fraud exists in the Exchange enrollment process. He says millions could be inappropriately enrolled. Conservatives say the enhanced Exchange subsidies that have now expired led to millions being enrolled due to zero or near-zero premiums. A number of brokers have been accused of fraudulently enrolling Americans. In January, enrollment in the Exchanges dropped about 1 million, which is far less than estimates. Conservative groups, including the Paragon Institute, have argued that so-called “shadow enrollees” remain in the program. Oz did say he expects enrollment to drop throughout the year to around 19 million. In part this is because of affordability issues due to premium hikes and people being unwilling to pay any premium. #exchanges #coverage #fwa https://thehill.com/policy/healthcare/5776734-oz-claims-aca-fraud-millions JEC Piles On Regarding MA

Balance And Bridge Proposed For GLP-1s The Centers for Medicare and Medicaid Services (CMS) has issued requests for applications for Medicare Part D plans and Medicaid agencies to join the BALANCE model that would bring GLP-1 weight-loss drugs to Medicaid and Medicare in 2026 and 2027, respectively, for those with obesity but not other qualifying disease states for the drugs. CMS will negotiate prices for such drugs with brand drug makers. Participating plans and Medicaid agencies must cover all model drugs from the included manufacturers, and the existing Part D weight-loss coverage exclusion would not apply. The drugs must fall under a plan’s basic benefit structure. In Part D, at least 90% of a plan’s eligible population must be included. Narrower risk corridors are available to plans. Enhanced alternatives and employer group waiver plans must cap beneficiary spending at $50 for a month’s supply during the initial coverage phase. For

Health Systems Report Financial Strength Large health systems are on the upswing financially right now, with improved margins, higher volumes, investment returns, technology-driven efficiency, and better cash flow. In addition to the positives cited, health systems are also investing in alternative revenue streams, such as specialty pharmacy and outpatient care. But storm clouds are moving in. Pharmaceutical and supply costs have posted sharp increases. And health systems face financial hits from the Medicaid and Exchange cuts in the One Big Beautiful Bill Act (OBBBA). (Article may require a subscription.) #hospitals #margins #obbba https://www.modernhealthcare.com/providers/mh-health-system-earnings-kaiser-mayo-clinic Health Affairs Forefront Blogs On ACOs and ACCESS Health Affairs Forefront has published a number of blogs on Accountable Care Organizations (ACOs) and the Medicare tech-enabled chronic disease ACCESS model. In one blog, the main question is: “Do ACOs actually save Medicare money?” It notes that the Congressional Budget Office (CBO) has concluded, on average, they do not

Other PBMs May Settle With FTC On Insulin Suits The Federal Trade Commission (FTC) may be close to settlement in its insulin suits with CVS Caremark and OptumRx, two of the remaining big 3 pharmacy benefits managers (PBMs). Express Scripts has already settled and any future settlements are expected to be as far-reaching in terms of impacting existing business practices. The FTC said in a court filing that it is making “significant progress” in talks with the two PBMs, Additional article: https://www.fiercehealthcare.com/payers/ftc-seeing-progress-discussions-optum-caremark-insulin-case #pbms #drugpricing #ftc https://www.healthcaredive.com/news/optumrx-caremark-progress-ftc-settlement-insulin-case/813834 Eli Lilly Launches DTC Platform Eli Lilly has officially launched Employer Connect, its direct-to-employer platform for its obesity medications. The program is aimed at supporting employer choice with multiple models. It will launch with more than 15 independent program administrators as partners. Lilly will offer Zepbound KwikPen to network pharmacies at a discounted $449 price. #glp1s #drugpricing #weightlossdrugs #employercoverage https://www.fiercehealthcare.com/payers/eli-lilly-launches-its-direct-employer-platform-obesity-drugs Hospitals Ask For Halt