epic

Biden No Surprises Act Interpretation Wins At Appellate Level After being struck down at the federal district level several times, the 5th Circuit Court of Appeals sided with the Biden administration’s original interpretation of the No Surprises Act in determining how a key metric in billing disputes is calculated. The court said that insurers can use a wider variety of rates in calculating the key qualifying payment amount (QPA) metric that helps arbitrators determine fair payment amounts. Now, the law remains heavily skewed to providers, who win three in four cases thus far in arbitration. The law itself favors providers in that it is baseball-style arbitration. The Biden administration wanted to tell arbitrators to give deference to the QPA, but this remains struck down by the courts. But the QPA determination is at least a small win that could begin to change things for the better. #nosurprisesact #nsa #surprisebilling #providers

Trump And Johnson Silent On Reforming Employer Healthcare Deductibility Donald Trump and House Speaker Mike Johnson, R-LA, are not saying whether they support the House Republican Study Committee’s (RSC) proposals to potentially cap the tax exclusion for employer-sponsored coverage. Employers can deduct premiums from federal and payroll taxes. Workers’ shares of premiums are also exempt from income taxes. These tax breaks cost about $300 billion combined a year today. The RSC is a conservative policy caucus within the House GOP members. Its proposal on employer healthcare tax deductibility is unclear, but its budget document certainly infers the deduction may be limited and it also calls for equalizing individual and employer deductibility. There are a few ways to limit the tax deduction, either capping what an employer can take outright or taxing individuals over certain amounts individually. Opponents argue the unfettered deduction drives up healthcare costs. To some degree this may

Bipartisan Senate Team Wants To Move On Site Neutral Payments Sens. Bill Cassidy, R-LA, and Maggie Hassan, D-NH, unveiled their support for a bill that would begin paying hospital outpatient facilities lower Medicare reimbursements much more consistent with what other places of service receive for the same services – known as “site-neutral” payments. The bill would equalize payments for common outpatient services at hospital-owned offsite locations, ambulatory surgery centers, and other clinics. Check out my blog on site neutral payments here:  https://www.healthcarelabyrinth.com/it-is-time-for-site-neutral-payments-in-our-healthcare-system/ . We know that the lack of site neutral payments cost us huge sums and we need to reform this in Medicare. Commercial payments would then be transitioned as many commercial plans base rates on Medicare. The hospital lobby’s ridiculous arguments may finally be giving way to common sense. Kudos to Cassidy and Hassan. We need full site neutral payments as quickly as possible. There is the possibility

Medicare Advantage Penetration Saves Medicare Dollars A new study from Elevance Health says that growth in Medicare Advantage (MA) leads to lower overall Medicare spending. This in part counters the shouts of MA opponents who cry about overpayments in the program. The study found that Medicare spending was $431 billion less from 2010 to 2020 than the Congressional Budget Office (CBO) predicted. The difference was per enrollee spending during the timeframe. The lower spending trend due to MA growth is most noticeable in midwestern and southern counties, but weaker in northwest and western counties. Researchers found that a 10% percent higher MA penetration in a county points to a 1.9% decrease in Medicare spending, correlating to a $204 decrease in per person spending. This resulted in up to $144 billion cumulative savings from 2012 to 2021. One theory is that higher penetration of MA introduces a change in provider behavior

Speaker Johnson Says Obamacare Not In Jeopardy With control of the U.S. House coming down to a small number of the 435 seats in the chamber, House Speaker Mike Johnson said today that Obamacare is not on the so-called hit list. While he acknowledged that healthcare reform is certainly on the agenda, he did admit that the Affordable Care Act (ACA) is part of the healthcare fabric. He disputed Democrats’ campaign assertions that he wants to repeal the law, saying: “The ACA is so deeply ingrained. We need massive reform to make this work, and we’ve got a lot of ideas on how to do that.” While Johnson said this, on the campaign trail Donald Trump and running mate JD Vance seem to indicate that they have a plan to introduce high-risk pools and move the adverse out of regular insurance pools.  Vance later claimed he meant reinsurance would be

CMS Touts ACO Savings Touting its efforts to reform the Medicare fee-for-service (FFS) program by using value-based payments and care, the Centers for Medicare and Medicaid Services (CMS) announced that the Medicare Shared Savings Program (MSSP) saved Medicare $2.1 billion in 2023, the largest yearly savings in the program’s history. The MSSP is also known as Accountable Care Organizations (ACOs). While this may have been the largest net savings, the reality is that there is at best a mixed record on the value-based care programs in the traditional system. Some studies suggest that the administrative costs of all of the programs exceed any savings. And the savings over time have been largely small. ACOs are perhaps the most successful, though. Additional articles: https://insidehealthpolicy.com/daily-news/cms-aco-stakeholders-tout-record-mssp-savings and https://www.cms.gov/newsroom/press-releases/medicare-shared-savings-program-continues-deliver-meaningful-savings-and-high-quality-health-care (Some articles may require a subscription.) #medicare #vbc #valuebasedcare https://www.fiercehealthcare.com/payers/mssp-acos-saves-medicare-21-billion-2023-largest-savings-program-history States and Medicaid Managed Care Plans Disagree on Rates While large Medicaid managed care plans

Coverage Expansion Saves Overall Healthcare Costs I absolutely loved this Health Affairs Forefront Blog arguing for an expansion of coverage and getting to true affordable universal access. It explicitly asks: “It is thus an ideal time to ask: Why aren’t we covering everyone and working to make care affordable for all?” The authors dissect well opponents’ positions that the Affordable Care Act (ACA) drove up costs and that trimmed down benefit packages are just fine. They beat down both arguments with good statistics. First, citing national healthcare expenditure data, they show that the ACA insurance expansions did not lead to accelerated cost growth. Second, they note that high-deductible health plans have negative impacts. Third, they argue that expansion might actually drive down cost growth more. They conclude that “we can have universal coverage, affordable cost sharing, and continued cost growth deceleration.” These points line up with my proposals for healthcare

OIG Says CMS Does Not Ensure Part D Denies Part A Drugs A new audit report from the Department of Health and Human Services Office of Inspector General (HHS OIG) is calling on CMS to enact certain reforms to prevent Medicare Part D from making additional payments for drugs that are supposed to be covered under the Part A benefit. Certain drugs that might normally be under Part D are under Part A when someone is in hospice or in certain facilities. Medicare Advantage and Part D plans should proactively determine what part of Medicare should be charged. This has been a long-standing issue in the Medicare program. The audit looked at more than 2.5 million prescription drug events (PDE) for 2018 through 2020. It looked at anomalies in a sample. Extrapolating the results, it says Part D improperly paid up to $465.1 million. About $245.4 million of that amount

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

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)