improperpayments

Scan Now Sues Over Clover Lawsuit And CMS Recalculations A new lawsuit has been filed by non-profit Scan Health Plan. Scan argues that CMS inappropriately recalculated Star Rating for 2026 after the Clover Health decision. Clover received an exact calculation based on the judge’s ruling throwing out 20 measures based on two legal arguments (10 measures were not statutorily allowed and another 10 measures were not properly promulgated via regulation). However, CMS’ recalculation measure set adopted part of the ruling by throwing out some of the judge’s measures, while retaining others. As well, CMS removed some measures not even struck by the court. Elevance Health was the first to sue, arguing it is entitled to a calculation based exactly on what the judge ruled for Clover on the 20 measures. Scan’s suit appears different. Scan argues the court should force CMS to remove the ten measures that CMS failed to

Wearables Growing But Not Integrated The use of wearables for disease monitoring has increased dramatically. About 86% of U.S. physicians report they sometimes review data from their patients’ wearables, including heart physiology, oxygen and breathing, and sleep. But only 6% of doctors say such data is integrated into clinical workflows and that clearly limits growth and  potential. The Trump administration has in part sought to leverage technology and overcome this deficiency by announcing the ACCESS reform pilot, which contracts with technology entities to partner with physicians to monitor chronic disease states. #chronicdiseases #technology #medicare #access https://www.healthcaredive.com/news/physician-wearable-data-use-hindered-workflow-reimbursement-challenges-american-medical-association/824640/ CVS CEO Says Aetna Has Turned Corner Financially At a public speaking event, CVS Health CEO David Joyner said insurer Aetna has finally gotten a handle on medical spending after a turbulent few years. Recently Aetna’s financial reports have shown recovery. In other health plan news: Elevance Health’s Medicaid subsidiary in the District of

Study Says Median Exchange Hike Will Be 14% Thus Far A Peterson-KFF Health System Tracker analysis finds that preliminary rate filings in the Exchanges will mean a median premium rate hike of 14% in 2027. This follows a final median hike of 20% in 2026 after plan switches. This would amount to a one-third increase over two years. While most of the hike will be covered by premium subsidy increases, the hikes will hurt those with little or no subsidy. Peterson-KFF looked at 77 insurers across 16 states and the District of Columbia. The healthcare duo calculated the enrollment-weighted average rate change across its offerings in a state. Most plans are requesting increases of between 10% and 20% for the coming year, though 20 payers have requested an increase of more than 20%. Plans say factors such as high medical costs, the expiration of enhanced exchange subsidies, and tighter enrollment

Pharmacy Group Alleges Price Fixing A community pharmacy group has filed suit against Prime Therapeutics, alleging that the company colluded with fellow pharmacy benefits manager (PBM) Express Scripts to fix prices and engage in anti-competitive behavior. The suit alleges Prime accessed Express Scripts’ network to slash prices. Additional article:https://www.modernhealthcare.com/insurance/mh-prime-therapeutics-lawsuit-express-scripts-pbm/ (Some articles may require a subscription.) #pbms #drugpricing #antitrust #pharmacies https://www.fiercehealthcare.com/payers/independent-pharmacies-hit-prime-therapeutics-antitrust-suit-over-alleged-price-fixing Private Equity Deep In Hospitals Private equity firms are expanding their healthcare reach through joint ventures with nonprofit health systems. A new report finds that more than 500 healthcare facilities operated through these nonprofit joint ventures. #privateequity #hospitals https://www.medpagetoday.com/hospitalbasedmedicine/generalhospitalpractice/122077 Tampa General Sues Eli Lilly On 340B Tampa General Hospital is suing Eli Lilly over its cut off of 340B discounts, saying that violates Florida’s Deceptive and Unfair Trade Practices Act. The hospital alleges the discount change forced the price of Mounjaro from $750.52 per unit to $1,019.74 at wholesale acquisition

ACA Exchange Risk Adjustment Settlements Total $11.7 Billion Health insurers will shuttle $11.17 billion between them due to the 2025 ACA Exchange risk-adjustment settlements. The settlements recognize differences in risk in the program in a given year. UnitedHealthcare will pay $335 million while Centene will receive $751 million, Elevance Health $312 million, Aetna $216 million, and Oscar Health $189 million. (Article may require a subscription.) #exchanges #riskadjustment https://www.modernhealthcare.com/insurance/mh-aca-exchange-risk-adjustment-payments-2025/ Exchange Rolls Saw Drops As Long As A Year Ago According to new data that was quietly published by the federal government, states began seeing steep drops in Exchange enrollment over the past year. Ohio and Oklahoma lost nearly one-third of enrollees. Florida has the most enrollees at nearly 4 million but lost the most at around 443,000. Around 2.6 million fewer Americans had Exchange plans in February compared with the same time last year. #exchanges #coverage #enrollment https://www.medpagetoday.com/washington-watch/washington-watch/122067 Dem Bill Targets

Paragon Proposes Reforms The influential Paragon Health Institute released a new report calling for federal funding cuts or tax reforms impacting all health plan lines of business and coverage areas. People pay attention to what Paragon says given its influence and impact on government regulations since 2025 as well as in the One Big Beautiful Bill Act (OBBBA). In summary, Paragon wants to see the following changes: #medicare #medicaid #exchanges #employercoverage #healthcarereform #healthcare #coverage https://paragoninstitute.org/medicare/restoring-fiscal-sustainability-to-federal-health-programs-reforming-the-incentives-that-drive-health-care-spending/ Balkanization of Star Ratings We are quickly seeing the balkanization of Star calculations for SY 2026. Elevance Health filed a suit against CMS today arguing that it should have used the Clover’s judge’s measures for recalculation rather than one created by the agency. Elevance says it lost out on $115 million in bonus payments as a result. Elevance has a point. How can one contract get the judge’s ruling while others receive the “better of”

MA Star Bonus To Exceed $13B Healthcare policy group KFF reports that federal spending on Medicare Advantage (MA) quality bonuses will reach at least $13.4 billion in 2026, compared with $12.7 billion in 2025. This is more than four times higher than in 2015. More than two-thirds of Medicare Advantage enrollees (68%) are in plans that qualify for the quality bonus in 2026, down from 75% in 2025. This is the lowest since 2018. The increase ties to more enrollment not better ratings. In another briefer, KFF updates on MA coding intensity. Additional article: https://www.kff.org/medicare/decoding-medicare-advantage-coding-intensity/ #medicareadvantage #radv #riskadjustment #stars #quality #cms https://www.kff.org/medicare/medicare-will-spend-more-than-13-billion-on-the-medicare-advantage-quality-bonus-program-in-2026/ Home Health Hike For 2027 The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would increase Medicare payments to home health providers by 2.4% in 2027. In addition, the rule would make it easier to bar providers and suppliers from Medicare over fraud. In

House Wants To Rein In Private Equity A bipartisan House bill would require extensive reporting on private equity firms’ healthcare holdings and ownership structures. The reporting is aimed at identifying financial arrangements that may impact the financial health of the healthcare entity as well as impacts on healthcare delivery. The bill is similar to state laws on transparency in private equity. Other states have gone deeper and ruled out certain financial arrangements by private equity for acquired healthcare entities. (Article may require a subscription.) #healthcare #congress #privateequity https://www.modernhealthcare.com/politics-regulation/mh-private-equity-healthcare-congress-transparency Providers Direct Contract With Employers There is a growing trend in providers direct contracting with employers. Local networks are leveraged and providers avoid prior authorization and other administrative burdens. Both employers and providers are cutting out the insurance middleman. (Article may require a subscription.) #healthplans #employercoverage #providers https://www.modernhealthcare.com/providers/mh-northwell-commonspirit-direct-contracting-employers Providers May Get Changes For Quality Reporting A new bipartisan House bill would allow

States Sue on Work Requirements Democratic governors and attorneys general from 25 states and Washington, D.C. are suing the Trump administration over the proposed Medicaid work requirements regulation. States argue the rule narrows exemptions for medically frail Medicaid beneficiaries and creates administrative barriers that could cause eligible people to lose coverage. The plaintiffs say the rule goes well beyond the statute by requiring people with serious health conditions to prove their condition significantly impairs their ability to meet work requirements. Additional: https://www.beckershospitalreview.com/legal-regulatory-issues/25-states-sue-trump-admin-over-medicaid-work-requirements-7-things-to-know/ and https://www.modernhealthcare.com/politics-regulation/mh-medicaid-work-requirement-lawsuit-democrats-bonta/ (Some articles may require a subscription.) #medicaid #workrequirements #states https://thehill.com/policy/healthcare/5946392-lawsuit-trump-medicaid-exemptions/ GLP-1 Bridge Population Healthcare policy group KFF finds that 3.8 million Medicare beneficiaries meet the criteria to be eligible for the new Medicare GLP-1 Bridge. The group looked at claims data from 2023. The proposed BALANCE program failed to attract enough plan participation. Instead, the Trump administration will run Bridge from July 2026 to Dec 2027.

Exchange Enrollment Falls Dramatically A number of analyses have predicted that Exchange enrollment nationally will fall in 2026 after dropping from 24.3M in 2025 to 23.1 in January 2026. The analyses said that enrollment would drop to as low as 17.5M as people would not be able to afford their premiums throughout the year. Sure enough, the predictions seem to have come true, and the news may be being buried. Today, a Health and Human Services (HHS) website posted an analysis on fraudulent and phantom enrollments and deep in the release were latest enrollment figures. HHS says around 19.2 million people are enrolled in the Exchanges as of now, a drop of about 4M since January. HHS says millions are inappropriately receiving subsidies, including individuals misstating their income to gain access to free plans and phantom enrollees (those who are unknowingly enrolled in free plans by unscrupulous brokers or are