unitedhealthcare

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)

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

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

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)