Is UnitedHealthcare Gaming Medical Expense Regulation?
A new study published in Health Affairs finds that UnitedHealthcare pays its owned providers at sister company Optum 17% more than those it does not own. And if United controls 25% or more of a market, that percentage increases to 61%. Researchers said the results suggest the company may be sidestepping government rules regarding calculation of medical expenses against premiums. If those rules are violated, rebates need to be sent to the government, employers, or individuals depending on the type of coverage. In effect, higher payments to owned providers would boost the so-called medical loss ratio (MLR) and more likely hit or exceed the required spending (usually 80% or 85%).
United says the study is wrong. And the study clearly has some limitations. It looked at just 14 CPT medical codes and about 385,000 transactions. But these were frequently performed and high-cost procedures in the commercial world. And to arrive at the over-reimbursement calculation, United payments were compared to what other large insurers, such as CVS’ Aetna, Cigna and Elevance Health, paid providers.
Notwithstanding United’s declarations to the contrary, the research would seem to be legitimate and reach a correct conclusion. It has long been a secret that vertically integrated health plans tend to sign lucrative deals with their own sister companies so as to inflate medical expense. It frees these organizations from a great deal of rebates and keeps the revenue in the family. It happens with payments to owned providers, at-risk payments to owned providers, higher payments to their own pharmacy benefits managers and specialty pharmacies, and payments to its own service entities. The good news is that transparency rules are now bringing some light to all this and congress is looking at the backroom deals.
Additional articles: https://www.healthcaredive.com/news/unitedhealthcare-pays-optum-doctors-more-than-other-doctors-study/804600/
#verticalintegration #healthplans #minimummlr #unitedhealthcare
Major Hospital Systems In Florida Create ACA Exchange Plan
Broward Health and Memorial Healthcare System, the two largest public health systems in Florida’s Broward County, have come together to create 22 Health, a new Exchange plan in Florida. This was in reaction to a contract dispute with Florida Blue. The two systems already have a plan together for Medicaid and children’s insurance. The new plan will offer bronze, silver, and gold coverage in the Exchanges.
Additional articles: https://www.modernhealthcare.com/mergers-acquisitions/mh-healthcare-deals-live-updates/ and https://www.beckerspayer.com/payer/2-florida-systems-partner-on-aca-plan/
(Some articles may require a subscription.)
#exchanges #fl #hospitals
Clover Health’s Financial News
Insurtech Clover Health’s revenue grew by 50% year over year in Q3. It had $496.6 million in total revenue for the quarter, up from $331 million in Q3 2024. For the nine months of 2025, revenues were $1.4 billion, compared to $1 billion for the same period in 2024.
The company, a Medicare Advantage plan, did have a $24.4 million net loss in the quarter, compared with $9.2 million in prior-year quarter. Clover has $36.2 million in losses so far in 2025, compared with $20.9 million in losses a year ago.
Clover does have challenges in the future. 97% of its current enrollment will be in plans less than 4 Star in 2026. That impacts payments for 2027.
#cloverhealth #medicareadvantage #margins
https://www.fiercehealthcare.com/payers/clover-health-sees-revenues-grow-50-year-over-year-q3
Moderate Democrats Could Agree To Open Government
Senate Democrats are divided over reopening government by offering 60 votes in the Senate, but some centrists could be swayed over to the GOP side to vote for short-term resolution to end the shutdown. Several centrist Democrats are signaling to their Republican colleagues that an agreement could be reached in the next few days. This is being aided by a side deal on an agreement to put the regular appropriations process back on track. Sticking points remain healthcare cuts and Exchange subsidies. While some say a strong victory for Democrats on Tuesday could mean Democrats dig in, others argue close races could open things up. Even an overwhelming victory could mean Democrats now concede on the issue.
Both leaders want a resolution that funds government through the end of January, while some centrists are discussing a mid-December cutoff.
Additional articles: https://thehill.com/homenews/senate/5587442-democrats-divided-shutdown-deal/
#governmentshutdown #congress #trump #healthcare #coverage #exchanges
https://thehill.com/homenews/house/5588431-speaker-johnson-end-date-funding-bill
— Marc S. Ryan
