socialsecurity

The Healthcare Labyrinth Blog’s Halloween Edition: More Gory News On HRAs and Manual Chart Reviews In Medicare Advantage

Latest investigative report will increase focus on Medicare Advantage risk adjustment In a May 9th blog here ( https://www.healthcarelabyrinth.com/will-cms-rein-in-risk-adjustment-submissions/ ), I made the case that a reasonable reform to tackle Medicare Advantage (MA) overpayments may be to bar MA health plans from getting credit from diagnoses reported only via health risk assessments (HRAs) and other manual chart reviews.  After all, enrollees should be treated by a physician for any disease states or conditions and providers should know their patients well enough to report all diagnoses over time on encounter or claim submissions. At the time, there was a growing body of evidence about the impact of HRAs and manual chart reviews on MA plan payments — specifically, that many plans were reporting diagnoses only from HRAs and manual chart reviews and not on subsequent encounters from doctors. The Department of Health and Human Services’ Office of Inspector General (HHS OIG)

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With Fraud Rampant, Federal Court Decision Could Kill “Qui Tam” Lawsuits

Striking major provision of qui tam lawsuits could hurt efforts to reduce fraud There is little doubt that fraud, waste, and abuse (FWA) is rampant in the American healthcare system. FWA ranges from gross inefficiency and poor use of healthcare resources all the way to outright illegal activity. In between there are all sorts of over-utilization and excessive testing. Outright fraud is up to 10% of our entire healthcare expenditures each year. FWA is likely up to 25%. With national healthcare expenditures expected to hit $5 trillion in 2024, up to $500 billion each year is fraud and $2.5 trillion is combined fraudulent, wasteful, or abusive spending. That is what makes the recent U.S. District Court of the Middle District of Florida decision on so-called qui tam lawsuits (I will call them qui tams from here on) very troubling. Federal Judge Kathryn Kimball Mizelle ruled last month that whistleblowers cannot file

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Election Is Close But Trump Has Electoral College Edge

A Trump victory would mean a sea change in healthcare policy The election is less than two weeks away. Given the huge sea change that could occur in healthcare policy, I thought it was time to devote a blog to my predictions on what might occur in the presidential, Senate and Houses races. I am a politics follower from way back. Early on in my career, I was a rightist youngster working for political action committees and political organizations. Later I was an editorial writer and political columnist prognosticating on state and local races. I also ran state legislative campaigns. As a governor’s appointee, I was smack in the middle of polls and political strategy. Predicting elections is a fool’s errand  What I learned through all of this is that predicting elections is very much a fool’s errand. It is never over until it is truly over and polls are

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What Is Happening To Big Healthcare And A Look At Its Future

Big healthcare right now looks rocky and it could get worse Just a few years ago, investors were absolutely enthralled with big healthcare – the massive companies that led vertical integration and seemed to be delivering strong margins and robust outlooks. But today, the investment community is concerned about a number of high-profile missteps from these big companies as well as external pressures that may force change. The big healthcare companies So, what companies are we talking about? Of course, I focus in on the big companies that have insurers as a major piece of their business – this includes UnitedHealth Group, Elevance Health, The Cigna Group, CVS Health, Centene Corp., Humana, and Molina Healthcare. Most of these entities have either large, concentrated insurance lines or are combination insurers and service providers. Let’s take them one at a time and discuss some of their missteps of late. UnitedHealth Group (UHG)

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Growth From September To October In Medicare Advantage

Enrollment in Medicare Advantage continues to climb as we enter enrollment season I decided to continue my Medicare Advantage (MA) monthly enrollment blogs because of continuing month-over-month increases. The growth is tied to remaining strong benefit packages for 2024. Increases in MA enrollment still occur outside of the enrollment season given the aging of America and the ability of some populations, such as dual eligibles, to continue to make changes throughout the year. New enrollees see huge value in enrolling in MA over the traditional fee-for-service (FFS) program. This value difference will continue to drive growth in 2025. Open enrollment began October 15 for 2025 benefits. We normally would see enrollment pick up a great deal in November and December as some switch to their new plans early. But that is unclear because many plans will rein in benefits and geographies for contract year 2025 due to significantly deteriorating bottom lines.

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Another Year Of Very Tough Medicare Advantage Star Measures Results

Note: This Healthcare Labyrinth blog was written and co-published in collaboration with Lilac Software, a new data analytics technology and insights firm I co-founded with Neetu Rajpal and Alex Schaefer. Lilac’s data scientists are hard at work analyzing all the Star Year 2025 results and recent trends. Check out Lilac Software’s website for additional research and analysis at https://lilacsoftware.com as well as Lilac’s LinkedIn page at https://www.linkedin.com/company/101172520/admin/dashboard/ . 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 have seen three years now of falling results – the 2023, 2024, and 2025 Star Years. In some ways the 2023 year was a “return to normalcy” (with apologies to President Warren G. Harding) after banner Star ratings in the two years prior that were driven

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CMS Should Institute Special Enrollment Period in 2025 For Medicare Beneficiaries

CMS needs to stop hiding the ball on coverage impacts and make amends for misleading Medicare beneficiaries I am generally a supporter of the Centers for Medicare and Medicaid Services (CMS). I think it tries very hard to help deliver quality care and regulate Medicare Advantage (MA) and providers reasonably. As a former government official and regulator, I am sympathetic to the agency’s need to constantly walk a tight rope when it comes to policy decisions. I have even backed some CMS decisions when the health plan industry has been vehemently opposed. But I am sorry to say that I have lost some faith in CMS recently. In blogs and newsfeeds I have questioned some of the agency’s actions. I see the agency reacting much more politically of late. This is especially true for MA and Part D decision-making in the last year or so. What happened in Medicare Advantage? While

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Docs Need Rate Relief In Medicare Program

The time has come for a real fix to Medicare physician fees. The big stall is hurting healthcare. Poor Medicare docs. They have been on a proverbial reimbursement roller coaster for decades now. The ups and downs have undermined independent practices, led to our primary care deficit, and actually fostered physician group acquisitions that increase costs in the healthcare system in several ways. More background A caution before I give you details on the history of Medicare physician pay — I am by no means a traditional Medicare fee-for-service (FFS) program rate expert. So, I am keeping this short and giving you a broad overview. The long and short of it is that Medicare physicians have had a rather broken rate system dating back to 1992. The bad system has been undermined further with various budget reduction requirements applied to the physician rates along the way. Congress created the Medicare

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The Biggest Lie Of The VP Debate: Trump Salvaged Obamacare!

Trump did not salvage the Affordable Care Act — he sabotaged it. Tall tales are always part of politics and candidate debates. America takes it for granted. But the biggest lie of the vice-presidential debate Tuesday night was quite the doozy and I could not let it go without some explanation. The big lie can be credited to GOP vice presidential candidate JD Vance. Vance attempted to concoct a story that somehow former President Trump salvaged the Affordable Care Act (ACA) when it was on the verge of collapse. This of course is true only in Vance’s and Trump’s minds. Vance’s fanciful rewrite of history went like this. Vance said Trump “actually implemented some of these regulations when he was president of the United States. … And I think you can make a really good argument that it salvaged Obamacare, which was doing disastrously until Donald Trump came along. I

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WSJ Editorial Wrong On FTC Lawsuit On PBMs

I promised to follow up on my newsfeed on The Wall Street Journal’s (WSJ) editorial on the Federal Trade Commission’s (FTC) lawsuit against the Big 3 pharmacy benefits managers (PBMs) – CVS Caremark, Cigna’s Express Scripts, and United’s OptumRx. I feel so much is wrong with what the WSJ editorial board is saying about the lawsuit. So here are some additional thoughts on the subject. The editorial is at a link below so you can read as well. What does the lawsuit charge? The FTC’s bombshell lawsuit charges that the PBMs have used formulary placement and rebates to rig the system and disadvantage the American public at the point of sale. While the FTC believes the anticompetitive activities permeate the entire system and apply to almost all brand drugs, it is focused in this lawsuit on insulin prices. The FTC says that the PBMs use the formulary and rebate scheme to

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