Pro Publica article recounts where health plans have not covered mandated services in state laws. It is easy to sensationalize mistakes, but health plans every day are approving treatments timely. (May require subscription.)
#plandenials #healthplans
The Healthcare Labyrinth Newsfeed will be off on November 23 and 24 for the Thanksgiving holiday. We will be back on November 27. Happy Thanksgiving to all! Stay safe!
— Marc S. Ryan
The new CMS 2024 Medicare Advantage (MA) rule prohibiting the use of most evidence-based criteria by MA plans is already being debated. Hospital lobbies are saying plans are out of compliance and January 1 has not even hit yet. Read my new companion blog at the blog tab on this site. I tell you why this rule is a terrible idea. Additional article here: https://www.modernhealthcare.com/politics-policy/health-plans-2024-medicare-advantage-rule-aha-cms-unitedhealthcare
#hospitals #medicareadvantage #medicare #ncd #lcd #priorauthorization
Kaiser Health News, the healthcare news aggregator, also does tremendous original news stories. One of its series is “Bill of the Month,” where it features one person’s heartache related to a recent healthcare bill. In this article, KFF intervened to get the patient’s bill cancelled, but she is among the lucky ones. It is also important to remember that not all surprise bills you receive will suddenly go away under the No Surprises Act. This surprise bill was from an in-network provider (hospital), which was charging outrageous lab fees on everyday tests. The health plan negotiated a poor discount and the patient’s plan had the insured covering a percentage of allowable costs.
The article touches upon the need for site neutral payments to lower costs in the system and protect consumer’s from high costs. Why should hospitals be able to set ridiculously high fees for services that could be done around the corner at a free-standing lab for sometimes pennies on the dollar? Another outrage here — the provider’s behavior. The provider appears to be a hospital-owned (or at least aligned) provider referring to hospital-owned entities (in this case, a lab). This is without regard to the patient’s best interests. The provider knows they will get a surprise bill. Today, over half of all doctors are owned by hospital systems and help further drive up costs by practicing at or referring to costly hospital-owned places of services.
#pricetransparency #hospitals #healthcarereform #siteneutral
CMS touts that improper payments were under 10% in traditional Medicare and in Medicaid, but it is nothing to be proud of. The traditional estimator of 10% for fraud, waste, and abuse (FWA) is a misnomer. Recent studies suggest that true FWA is perhaps 25% of all healthcare expenditures. In 2021, healthcare expenditures were $4.3 trillion. That means almost $1.1 trillion is true FWA.
#fwa #medicare #medicaid
With a large proportion of the 10M Medicaid disenrollees cut from the program for procedural reasons, a group of civil rights entities are issuing report cards to states. The report cards seek to call out whether each state has done the necessary due diligence during unwinding to ensure those who remain eligible retain coverage. While states and the Centers for Medicare and Medicaid Services (CMS) are at some fault, Congress is really to blame for not passing legislation that allowed for a longer transition time.
#medicaid #redterminations
The Centers for Medicare and Medicaid Services (CMS) is mandating that State Exchanges follow federal network adequacy as well as open enrollment periods, among other changes.
#networkadequacy #cms #aca #exchanges #obamacare
Congratulations to the Kaiser Family Foundation and The New York Times on the first in a series of articles on America’s long-term care crisis. America needs an aging policy. The series shows real-life examples of the impact of not having a national agenda on aging. It clearly shows that the lack of adequate supports for the elderly also impacts other generations, including children’s loss of income to take care of an elderly loved one.
In my book (available for purchase on this website), I devote a chapter to aging and recommend ways to make services available to all in an income-based buy-in strategy. Not addressing aging will only drive long-term care and medical costs even higher in the future. In addition to the NYT story and press release at the link below, here is a link to the KFF summary of a survey on long-term care: https://www.kff.org/health-costs/poll-finding/the-affordability-of-long-term-care-and-support-services/
#aging #ltc #medicare #medicaid #kff #nyt
Despite some notable failures in the health tech world and tightness in equity markets, deals and mergers continue. Two notable examples in this article.
#digitalhealth #healthtech
A series of startup PBMs are seeing some success signing up health plans by riding the price transparency train. They have even set up their own trade group to differentiate themselves from traditional PBM lobbying efforts. An interesting development, but one that will take time to break the dominance of the three giants, which control about 80% of all the business. (may require subscription)
#medicareadvantage #commercial #medicaid #pbms #pricetransparency
