Centene Next To Sue CMS Over Star Ratings
Centene has become the latest big Medicare Advantage (MA) plan to sue the Centers for Medicare and Medicaid Services (CMS) over its 2025 Star ratings. United and Humana have already done so.
As with the other two plans, Centene argues with CMS’ call center measures. Its complaint raises three fundamental issues. First, relying on a handful of secret shopper calls in a given measure is unreasonable. Second, the 5-Star score requires 100% of TTY calls to be successfully completed and inclusion of even a single incorrect TTY call in the denominator has significant negative impact. Third, CMS mishandled and scored one TTY call to Centene’s detriment.
Centene says the one call will cost the plan $73 million in revenue.
In other news, brokers and agents are very worried about the impact of major reductions in the MA and standalone Part D (PDP) plans. They say that demand for Medicare Supplement policies will surge. The good news is that most states allow Medicare supplement carriers to underwrite policyholders switching from MA without underwriting.
In addition, agents and brokers note that MA and PDP plans are limiting or eliminating commissions. WellCare will not pay for selling PDP plans, Aetna will not pay for new PDP members, and Humana and Cigna will not pay for new members in certain PDPs.
Additional articles: https://www.healthcaredive.com/news/centene-medicare-advantage-star-ratings-lawsuit-hhs/730696/ and https://www.beckerspayer.com/payer/one-phone-call-cost-centene-73-million-lawsuit-alleges.html and https://www.modernhealthcare.com/insurance/centene-medicare-advantage-star-ratings-lawsuit and https://www.modernhealthcare.com/insurance/insurance-brokers-banking-consumers-medicare-confusion
(Some articles may require a subscription.)
#medicareadvantage #agents #brokers #marketing #coverage #cms #stars
https://www.fiercehealthcare.com/payers/not-be-left-out-centene-sues-cms-over-2025-star-ratings
Elevance’s Anthem of New York Accused Of Having A Ghost Network
Anthem Blue Cross Blue Shield of New York is facing a class-action suit over the fact that most mental health providers in its directory constitute a ghost network and do not accept patients, which means inability to access services and seeking care out-of-network.
#access #coverage #healthcare #commercial
Change Healthcare Cyberattack Was Biggest In History
The massive Change Healthcare cybersecurity attack has been named the single largest breach in history. The ransomware attack in February affected 100 million people, or nearly 30% of the U.S. population.
(Article may require a subscription.)
#cyberattacks #changehealthcare
https://www.modernhealthcare.com/cybersecurity/change-healthcare-breach-cyberattack-unitedhealth
Current PBM Model Called “Dead Man Walking”
At HLTH 2024, executives from health insurers as well as Amazon’s online pharmacy, retailer Walgreens, and the brand drug maker lobby all called for greater transparency and an end to the current pharmacy benefits manager (PBM) models.
Blue Shield of California (BSC) has teamed up with some prominent entities to migrate away from the traditional PBM model toward a transparent one to lower costs and improve quality. While PBMs refute the argument, many argue PBMS are pushing brand drugs at the expense of some generics due to rebates.
#drugpricing #pbms #branddrugmakers
ACAP Recommends MA Coding Reform
In a new report, the Association of Community-Affiliated Plans (ACAP) is highlighting recommendations for reforming Medicare Advantage (MA) risk adjustment coding. It is concerned about overcoding but also that MedPAC, the congressional policy arm, calls out that dual-eligible Special Needs Plans (D-SNPs), may actually have undercoding due to the frail and social determinant nature of enrollees in these plans. Scores for these plans declined by 3% from 2017-2021, while other plan scores increased by 6%.
ACAP recommends several reforms, including allow D-SNPs to continue using health risk assessments (HRA) and manual chart reviews if these are sunset overall, updating risk adjustment to lessen the reliance on encounter collection, and considering having tiered risk adjusters based on coding intensity of the plans.
I have called for an end to using HRAs and chart reviews as the sole method for determining eligibility of a diagnostic code in risk adjustment. ACAP’s concept of a tiered risk adjuster is interesting.
(Article may require a subscription.)
#riskadjustment #medicareadvantage #specialneedsplans #snps
https://insidehealthpolicy.com/daily-news/safety-net-plans-offer-recs-addressing-ma-coding-intensity
Analysis Suggests MA Plans Not Fully Complying With Two-Midnight PA Change
A new analysis from Kodiak Solutions says that Medicare Advantage plans may not be fully complying with the new two-midnight requirement promulgated by the Centers for Medicare and Medicaid Services (CMS). The prior authorization change from CMS requires plans to follow fee-for-service (FFS) rules in terms of what services are covered. In the case of an inpatient stay, providers alone decide whether it should be covered. In most cases, the service must be provided if the doctor says the individual will need inpatient care for at least two midnights.
Kodiak says its analysis of trends for observation and inpatient days suggests payers are “continuing to apply their own criteria for inpatient admission and dismissing the two-midnight rule for Medicare beneficiaries.”
CMS has yet to really scrutinize the PA changes in its program audits. Hospitals are turning up the heat on this and CMS likely will begin to audit the PA rules in a major way.
#priorauthorization #cms #medicare #medicareadvantage
Novo Nordisk Wants FDA To Stop GLP-1 Compounding
Novo Nordisk wants the Food and Drug Administration (FDA) to bar compounding pharmacies from creating their own versions of Ozempic and Wegovy. Compounders are allowed to fulfill patented drugs when the brand is in short supply. There also is an exception to meet individual needs. Compounders argue both provisions apply right now to Novo Nordisk GLP-1 products. Novo is arguing the drugs are too complex for the pharmacies to make safely. Novo’s GLP-1s cost in excess of $1,000 a month, whereas most compounded versions are in the $200 range.
#weightlossdrugs #glp1s #branddrugmakers #drugpricing
https://thehill.com/policy/healthcare/4949996-novo-nordisk-fda-ozempic-wegovy-semaglutide
— Marc S. Ryan