Newsfeed

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

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

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 basic alternative and actuarially equivalent plans, the cap is $125 per month supply. Prior authorization would also be standardized across the model. The documents outline body mass index thresholds, provider attestation, and confirmation that patients are pursuing lifestyle modification.

CMS is also proposing a pilot in Medicare known as the Medicare GLP-1 Bridge to begin providing coverage as early as mid-2026. Wegovy and Zepbound would be provided to eligible beneficiaries enrolled in Medicare Part D for a $50 copayment. The short-term program will operate outside the Part D benefit for its duration from July 1 to December 31, 2026. Providers will submit GLP-1 prescriptions and prior authorization requests to a central processer managed by CMS.

Additional https://www.kff.org/quick-take/what-medicares-temporary-program-covering-glp-1s-for-obesity-means-for-beneficiaries/

#glp1s #weightlossdrugs #medicare #partd

https://www.beckerspayer.com/policy-updates/cms-invites-medicare-part-d-plans-medicaid-agencies-to-apply-for-glp-1-affordability-model/

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

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

Study Finds Multiply Comorbid Drive Inpatient Admissions

A new report by Vizient finds that 11% of the U.S. population has multiple chronic conditions but these patients account for 52% of inpatient admissions, 35% of emergency department visits, and 32% of office visits. Patients with at least one chronic condition make up nearly 8 in 10 inpatient admissions. 

Among Medicare beneficiaries, more than half of those aged 65 to 74 have at least one chronic condition, and the same is true among nearly two-thirds of those 75 and older. This creates huge cost challenges in Medicare as America ages. Controlling chronic disease states is key.

#aging #medicare #hospitals #chronicconditions

https://www.beckershospitalreview.com/quality/patient-safety-outcomes/11-of-us-population-accounts-for-52-of-admissions-vizient/

Plans Oppose Flat 2027 MA Rates

In comments on the proposed 2027 Advance Notice of rates, Medicare Advantage (MA) plans say a flat rate will mean reduced benefits and services and increased out-of-pocket costs for seniors. UnitedHealth Group estimates the proposed rate increase would lead insurers to reduce benefits by more than $600 a year. AHIP says its actuary Wakely determined no-premium plans could face a 50% cut to supplemental benefits and increased out-of-pocket costs by $1,000. Premiums could increase $23 per month, resulting in a jump of more than $550 for a couple each year.

The plans also argue rising utilization and costs are being ignored.

In addition, Humana, insurer trade group AHIP, and the Blue Cross Blue Shield Association want the proposed changes to risk adjustment regarding chart reviews not linked to encounters to be delayed until 2028. UnitedHealth Group and the Better Medicare Alliance recommend that CMS implement this change gradually rather than all at once next year. AHIP and the Alliance of Community Health Plans say plans should be able to use chart reviews to score new members.

I expect final rates to increase by between 2% and 3%.

Additional article: https://www.beckerspayer.com/research-analysis/benefits-coverage-for-no-premium-plans-could-drop-50-under-2027-ma-rule-ahip/

(Some articles may require a subscription.)

#medicareadvantage #rates #riskadjustment

https://www.modernhealthcare.com/politics-regulation/mh-cms-2027-medicare-advantage-proposal-unitedhealth

Regional MA Plans Surged In Open Enrollment

Becker’s Payer interviewed several executives at regional plans that grew tremendously during the Medicare Advantage (MA) open enrollment season as most big national plans contracted and shed lives. Medicare Advantage enrollment grew less than 1% for open enrollment, but regional plans grew by 443K while national plans dropped by 328K. Seniors benefited from the continued commitment of the regional plans.

Health Alliance Plan in Michigan added more than 37,000 new enrollees in open enrollment, a 58% increase. Priority Health added more than 35,000 new members in open enrollment. SCAN Group added 127,000 new members during open enrollment. The growth pushed SCAN into the top 10 nationally among MA plans. Alignment Healthcare grew 31% year over year in 2025 to roughly 276,000 total members. Network Health grew 37% during open enrollment to 126,000 total MA members.

#medicareadvantage #enrollment

https://www.beckerspayer.com/payer/medicare-advantage/were-running-in-when-others-are-running-out-stability-drives-record-growth-for-regional-medicare-advantage-plans/

Independent Physicians Embrace PE

A good article discussing the plight of independent physician practices. With about half of physicians now owned by health systems and many of the remainder owned by public equity and health plans, standalone practices are suffering. Medicare rates have increased just 10% since 2001, yet costs are up for practices by 63% in that time. Medicare rates drive commercial rates. Independent practices are getting creative to survive, including teaming up with public equity firms that own medical service organizations and tapping into their services and capital, while remaining free-standing.

(Article may require a subscription.)

#physicians #independentpractices

https://www.modernhealthcare.com/providers/mh-independent-physicians-private-equity-partnerships/

MA Plans Object To Flat 2027 Rates

The Medicare Advantage (MA) community was shocked by the near-flat rates that the Centers for Medicare and Medicaid Services (CMS) proposed for 2027. MA plans are now laying out the potential impacts in comments on the proposed regulation.

The rate hike was computed at just 0.09% due to two new risk adjustment reforms – one embedded in the new v28 model and another that bars risk scoring unless diagnoses also appear on submitted provider encounters. The changes wiped out the economic growth increase.

Various MA plan trade groups were unanimous in saying that the rate as is could undermine the program yet again. Major health plan trade group AHIP said in comments to the proposed rule that the flat rate “risks undermining CMS’ goal of providing beneficiaries with stable, affordable choices during the annual enrollment period.” It noted sharply rising medical costs and high utilization in the program. It cited an analysis from actuarial and consulting firm Wakely that member premiums could increase by $23 per month if insurers maintain existing benefits — $550 per year for a couple. Wakely said benefits might have to be cut by 50% to maintain $0 premiums, including important vision and dental benefits, and out-of-pocket costs could surge by $1,000.

The Blue Cross Blue Shield Association said that smaller, regional Blues plans have fewer avenues to absorb revenue losses in MA compared to the big MA plans. The Better Medicare Alliance, which advocates for consumers, said the disruption that occurred in the 2026 open enrollment, including record forced plan changes, would worsen.

I do not think CMS will back off of the risk adjustment proposals, but I do expect the final economic growth numbers to grow by between 2 and 3 percent, which will give some relief. But it will still mean major reductions again in 2027.

#medicareadvantage #rates

https://www.fiercehealthcare.com/regulatory/insurance-groups-say-proposed-flat-medicare-advantage-rates-fail-meet-moment