audits

Medicare Advantage Insurers Focusing On Special Needs Plans And Growth Shows It

December 4, 2023 No Comments

While Medicare Advantage (MA) has seen huge increases in enrollment since the beginning of the decade, forecasts suggest that enrollment growth will be reduced moving forward. Many things factor into the slowdown, including a new rate environment, poor Star performance, and reaching saturation in certain areas of the country. Nonetheless, MA continues to be a strong program and the most-lucrative place to be if you are an insurer. One segment of the MA program, Special Needs Plans (SNPs), however, are destined to continue to grow significantly moving forward. This is driven in part by policies from the Centers for Medicare and Medicaid Services (CMS) and the significant financial opportunity plans see. As of November 2023, SNP and related program enrollment stood at over 6.6 million. That is a 15% growth since January 2023. There are three types of SNPs: (1) Institutional SNPs or I-SNPs (the individual is a resident of

American Healthcare Is A Huge Outlier In Terms Of Costs and Outcomes

November 30, 2023 No Comments

I am writing this blog from the United Kingdom on the occasion of the 75th anniversary of the National Health Service (NHS). The British newspapers this year, as they were five years ago for the 70th Anniversary, were filled with a curious mix of messages about the NHS. On the one hand, Britons defend the NHS and take pride in the system that has been built over the last 75 years. The NHS is always at or near the top of the most important issues at election time. At the same time, Britons are frustrated with many elements of the system, including long wait times and the hoops that must be jumped through for certain services as well as notable staff shortages and other deficiencies. Some blame the miserly increases given to the NHS during the conservative government’s tenure over the past decade or so. The 75th anniversary of the

The Importance of Price Transparency In Healthcare Reform

November 27, 2023 No Comments

While website postings of hospital and health plan negotiated prices may not seem of particular importance, the nation’s modest move toward price transparency should bear fruit over time. It is one of the more important initiatives we have seen in healthcare reform as of late. With interoperability of data, price transparency will finally give us some useful information on the inner workings (even machinations) of negotiations between health plans and providers. What are the price transparency requirements? Both health plans (effective July 1, 2022) and hospitals (effective January 1, 2021) have been required to post various pricing information on their websites. Hospitals must report all their gross and net charges in a machine-readable format as well as at least 300 shoppable services (cash and payer prices) in a consumer-friendly format. Health plans must report allowed amounts and contracted rates for hospitals and other provider services for all in-network covered services

CMS’ Medicare Advantage Utilization Management Rule Sets A Terrible Precedent

November 22, 2023 No Comments

I have mentioned the new 2024 Medicare Advantage (MA) Utilization Management (UM) rule in two of my blogs recently. But here is a relatively short one to drive home the idea that the rule sets a terrible precedent. What does the rule do? It takes external evidence-based criteria off the table in favor of the policies used in the traditional Medicare program. Unless a FFS policy is not fully established, an MA plan must rely strictly on the traditional FFS program criteria instead of outside evidence-based clinical criteria. “Fully established” is not well defined, but CMS likely will argue that the NCDs and LCDs are fully established except in some small and extreme circumstances. Let’s set my argument up with three points. First, the rule was a direct result of the aggressive lobbying by provider groups opposed to the growth of managed care in Medicare. The Biden administration is sympathetic

Medicare Advantage Will Have Huge Challenges Ahead

November 20, 2023 No Comments

Medicare Advantage (MA) has been known as the most profitable sector of any health plan. With high premiums, a lucrative Star quality bonus, and chance to reduce medical expenses compared to the traditional fee-for-service program, plans have been able to register higher percentage and overall dollar margins in MA as compared with commercial and Medicaid. But as we have seen throughout the last few years, MA is not without its challenges and that will continue into the future. Surprisingly, at least one major player could be shopping its Medicare Advantage portfolio and getting out of the business. Here are the top challenges I see and areas MA plans need to keep an eye on. The collapse of the insurtechs Just a few years ago, the insurtechs were the darlings of investors. Investors believed that the insurtechs would leverage technology to transform healthcare, reduce costs, and drive quality. The investors also

2024 Star Ratings Turmoil Creates Huge Vulnerability for Medicare Advantage Plans

November 16, 2023 No Comments

While the Medicare Advantage (MA) Star Program has always made it difficult for plans to achieve and maintain high Star scores, the Star roller coaster ride has been much more profound over the past several years. We now have had two years of pretty bad news, which puts a blemish on the program (fair or not). What’s more, the percentage of high-scoring contracts and the percentage of enrollment in them are now below pre-COVID years. To refresh a bit on this, during the COVID pandemic, the Centers for Medicare and Medicaid Services (CMS) created fairly major calculation allowances for both Star 2021 (2019 and 2020 data) and 2022 (2020 and 2021 data). These allowances had the effect of boosting Star scores. We saw a surge in Star scores in 2022, including for plans that historically did not have a great track record of consistently hitting 4 Stars and above. However,

Major Changes in Medicare Advantage Oversight

November 13, 2023 No Comments

The Centers for Medicare and Medicaid Services (CMS) have been active this year proposing major new restrictions on Medicare Advantage (MA) plans. Many of the changes are in reaction to provider lobbying efforts on Capitol Hill as well as public outcry over misleading tactics by third-party entities who enroll individuals in the popular senior and disabled plans. Let’s start out with the changes effective January 1, 2024, from the 2024 MA and Part D rule finalized earlier this year. It is important to note that CMS issued a memo that states that it will enforce the 2024 rule beginning January 1, 2024. Usually, such rules are enforced through the regular program audit process and it takes a number of years before regulatory changes are rolled into the audit protocols. That seemed fair as major changes take time for plans to implement. But in the October 24, 2023, memo issued through