October 24, 2024

HHS OIG Accuses MA Plans Of Inflating Risk Adjustment Submissions

In a follow-up to an earlier review, the Health and Human Services’ Office of Inspector General (HHS OIG) concluded that Medicare Advantage (MA) insurers could be using health risk assessments (HRAs) to inflate risk adjustment payments through upcoding. The OIG says an estimated $7.5 billion in risk-adjusted payments tied to HRAs was received by MA insurers but the diagnoses substantiating them did not appear on separate encounters.

Just 20 MA companies drove 80% of the questionable revenue. HHS OIG recommends a series of reforms. UnitedHealth Group received two-thirds of such risk-adjusted payments despite only managing 28% of MA enrollees. I have previously said MA plans should get ready for restrictions or elimination of HRAs and chart reviews in risk adjustment. However, the Centers for Medicare and Medicaid Services (CMS) did not concur with the HHS OIG findings, saying the study was not definitive.

I will have an in-depth blog on this next week and recap all studies on the subject out there.

In other MA news:

  • A good article summarizing the 2025 Star Year controversy and why three big plans are suing CMS.
  • An article summarizing market exits and benefit terminations, most of which are from Humana, Aetna, and United Healthcare.
  • An article on how plans are approaching the enrollment season given major cutbacks.

Additional article: https://www.modernhealthcare.com/policy/medicare-advantage-overpayments-cms-oig-2023 and https://www.beckerspayer.com/policy-updates/medicare-advantage-plans-made-7-5b-from-questionable-assessments-in-2023-oig.html and https://www.modernhealthcare.com/legal/humana-unitedhealthcare-medicare-advantage-star-ratings-lawsuit-cms-hhs and https://www.beckerspayer.com/payer/medicare-advantage-market-exits-causing-the-most-disruption.html and https://www.beckerspayer.com/leadership/how-medicare-advantage-plans-are-approaching-a-tumultuous-open-enrollment.html

(Some articles may require a subscription.)

#medicareadvantage #cms #riskadjustment #stars

https://www.fiercehealthcare.com/payers/medicare-advantage-plans-received-billions-medicare-home-visits-feds-are-skeptical

Harris and Trump Have Different Views On ACA

The Hill reviews the vast differences between Trump and Harris on the Affordable Care Act (ACA). Harris would vigorously protect Obamacare and seek to extend the enhanced premium subsidies. While Trump has tried to have a balanced view on the ACA, more recently his vice presidential partner, JD Vance, has raised possible changes that look like past failed policies.

Another article outlines what Harris would do if elected:

  • Expand certain Medicare services.
  • Expand drug price negotiations and other reforms.
  • Whether she could get enhanced subsidies extended or permanent depends on control of Congress.
  • Reducing medical debt.
  • Expanding the No Surprises Act to ground ambulances.

Additional article: https://www.statnews.com/2024/10/24/kamala-harris-election-win-could-bring-health-care-policy-changes/

#exchanges #obamacare #aca #drugpricing #medicare #election2024 #harris #trump

https://thehill.com/policy/healthcare/4945335-harris-trump-obamacare

MultiPlan Sued Again

MultiPlan, a major vendor for health plans, is facing another antitrust lawsuit from providers. The American Medical Association (AMA) alleges the data analytics firm worked with insurers to allegedly depress out-of-network physicians’ pay. The AMA and other provider lobbies want the federal court to state MultiPlan’s work with insurers is illegal and issue an injunction. The suit says that since MultiPlan works with 700 insurers the out-of-network payments it negotiates are anti-competitive and amount to price fixing.

(Article may require a subscription.)

#healthplans #providers #multiplan

https://www.modernhealthcare.com/legal/multiplan-ama-illinois-state-medical-society-lawsuit-antitrust

Molina Healthcare Exceed Expectations

Molina Healthcare is seeing its stock rise dramatically after the company easily beat third quarter earnings. It says it expects Medicaid rate hikes in many states and will buck the trends of other Medicaid managed care companies that are facing major mismatches between rates and medical expense tied to increased adversity of members. This should boost 2H 2024 revenue by $350 million.

Molina will not offer regular Medicare Advantage (MA) plans in 13 states next year, accounting for $200 billion in annual premiums. But it will continue to provide Special Needs Plans (SNPs) in MA and focus on dual eligibles.

Additional articles: https://www.fiercehealthcare.com/payers/molina-healthcare-stock-soars-after-beating-q3-earnings and https://www.modernhealthcare.com/medicaid/molina-healthcare-medicaid-pay-reimbursement

(Some articles may require a subscription.)

#molina #medicareadvantage #medicaid #managedcare

https://www.healthcaredive.com/news/molina-medicaid-third-quarter-results/730862

FDA Commissioner Criticizes GLP-1 Brand Manufacturers

FDA Commissioner Robert Califf criticized the producers of GLP-1 weight loss drugs, saying the drugs’ prices are outrageous and are unfair to lower-income Americans. He also said the companies are not keeping up with demand. The FDA is currently allowing compounders to produce the drugs due to the shortages. He hinted at the potential for additional reforms.

(Article may require a subscription.)

#drugshortages #weightlossdrugs #glp1s #fda

https://insidehealthpolicy.com/inside-drug-pricing-daily-news/califf-bashes-glp-1-drug-pricing-hints-future-fda-action

— Marc S. Ryan

Leave a Reply

Your email address will not be published. Required fields are marked *

Available Now

$30.00