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 Overpayments
The bipartisan congressional Joint Economic Committee (JEC) concluded that overpaying for Medicare Advantage (MA) plans caused Medicare Part B premiums to rise across the board. It says the overpayments caused standard monthly Medicare Part B premiums to go from $185 in 2025 to $203 in 2026. The JEC defined “overpayments” as the difference between what the federal government paid for MA plans versus traditional Medicare. It cited statistics that MA plans were paid $84 billion more than it would have cost to cover the same amount of beneficiaries with traditional Medicare. The report urged action.
“Today, between aggressive upcoding, questionable quality bonuses, and structural overpayments in Medicare Advantage, seniors who stay in traditional Medicare are effectively subsidizing the system. That’s not sustainable, it’s not fair, and it can be reformed,” said Chair Rep. David Scweikert, R-AZ.
Of course, the JEC are using erroneous and politically motivated analyses from congressional policy arm MedPAC and anti-MA academics. See my recent blogs to learn more: https://www.healthcarelabyrinth.com/reports-of-mas-death-are-greatly-exaggerated/ and https://www.healthcarelabyrinth.com/ma-overpayments-remain-controversial-but-could-part-of-the-argument-be-going-way/ .
#medicareadvantage #overpayments #riskadjustment
https://thehill.com/policy/healthcare/5777186-medicare-advantage-overpayments-raise-premiums
Centene Stock Nosedives
After its CEO made remarks at Barclays Global Healthcare Conference, Centene’s stock took a nosedive. Sarah London offered frank remarks on the Exchange. She said its Exchange plan dropped to 3.6 million as of February, from 5.5 million at the end of 2025. She said the executive team expects that to decline further to about 3.5 million by the end of Q1. At the same time, she said the drop meets expectations communicated to investors.
She also noted that Centene is seeing a shift in enrollment in different metal tiers. Silver enrollment has dropped to 50%, while Bronze is in up to the mid-30s. Centene is seeing older people now in lower cost plans.
#exchanges #centene
Elevance Expands Hospital Penalty
Elevance Health is expanding a policy to deduct pay from hospitals that refer some members to out-of-network providers. Beginning June 1, California hospitals’ pay may be reduced by 10% or have their contracts terminated if hospitals refer commercial members to inpatient or outpatient providers without a contract.
(Article may require a subscription.)
#elevancehealth #hospitals
https://www.modernhealthcare.com/insurance/mh-elevance-out-of-network-provider-policy
Work Requirements And Provider Tax Restrictions Hit State Medicaid Budgets
Work requirements and provider taxes continue to challenge states in a number of ways, including state budgets and planning for the complex implementations. The work rules kick in on January 1, 2027 and states complain about little guidance. States also will have their ability to levy provider taxes restricted. All of this will mean the state share of Medicaid will increase. $960 billion in Medicaid cuts will occur over ten years under the One Big Beautiful Bill Act.
(Article may require a subscription.)
#medicaid #obbba #providertaxes #workrequirements
https://www.modernhealthcare.com/politics-regulation/mh-medicaid-work-requirements-states-2027
— Marc S. Ryan
