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This is Jacob I sent with the Becker

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payer issues podcast.

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Here's your bi weekly industry news briefing for

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June 20 sixth. Lawmakers are pushing Cms to

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do more to prevent misuse of artificial intelligence

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by Medicare advantage plans. A group of 51

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lawmakers signed a letter to Cms administrator, Chi

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Brooks asu on June 20 fifth.

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Asking the agency to implement more stringent oversight

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regarding the technology.

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In November, families of 2 United health Medicare

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advantage members sued the company, alleging that Nav

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Health an Ai algorithm owned by Opt, wrongfully

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denied the members post acute care. An Opt

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spokesperson previously told backers that the product is

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not used to make coverage

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determinations. In their letter, the lawmakers wrote, they

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remain concerned about M plans use of prior

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authorization, specifically their ongoing use of artificial intelligence,

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algorithm software to guide coverage decisions.

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Plans continue to use Ai tools to erroneous

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deny care and contradict to provider assessment findings.

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In February, Cms published guidance on how Ai

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can be used by M plans. In its

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guidance, the agency said payers can use out

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to support coverage decisions, but is their responsibility

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to ensure that an algorithm or Ai based

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tool is compliant with Cms requirements.

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M plans can use algorithms only to predict

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length of stay for post acute services, and

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not as the basis for terminating coverage.

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At a February hearing, experts told members of

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the Senate Finance committee that Cms is guidance

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may not be clear enough to prevent misuse

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of.

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In their letter, the lawmakers urged Cms to

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implement more specific guidance around how plans can

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use Ai. The legislators are asking the agency

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to create an approval process. Us to vet

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new Ai tools used by insurers and to

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prohibit the use of Ai tools and coverage

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decisions until the agency has completed Asus systematic

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review.

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Well Blue Shield of California has fired a

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top executive for allegedly lying about her medical

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credentials.

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Tasha Lara La was previously the interim vice

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president, Chief Medical Officer and the medical director

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of medical management and accreditation, and Blue Shield.

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The company told Backers, it has it had

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learned a former employee, quote, misrepresented her name

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and licensure, and so they reported the matter

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to law enforcement.

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Miss lara La is listed as a doctor

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of os homeopathic medicine in an archived version

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of blue builds corporate leadership page. There is

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no record of her in the licensed date

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In the licensing database of the Os path

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Medical Board of California

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The individual... She did not treat patients and

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her role was primarily

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administrative. The company told Becker that because this

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is an active fraud investigation as well as

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a personnel matter. They cannot discuss more details,

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but they are confident the authorities will conduct

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a thorough

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investigation and they are committed to supporting that

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effort.

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Well the Us Supreme Court has declined to

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hear Home Depot challenge to a 2670000000.00

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up settlement with Blue Cross Blue Shield companies,

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ending a legal saga over alleged and competitive

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behavior the Dates valor back to 20 12.

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The court also rejected a related challenge for

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a 667000000

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dollar fee award for the attorneys who were

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involved with the settlement.

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Now Bc cbs members first brought this case

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back in 20 12, alleging that Bc cbs

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companies conspired to divide up markets to avoid

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competing with each other, thereby driving up costs

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for consumers.

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In 20 20, Bc cbs companies and the

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Association reached that 2700000000.0

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dollar settlement, in which Bc admitted to no

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wrongdoing.

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That settlement mandated the Bc companies drop an

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association rule that required 2 thirds of national

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net revenues from health plans and related services

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to come from blue branded products.

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Another rule, the settlement struck down had required

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large employers to work with the blue insurer

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that offers coverage where the employer is. Headquartered

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so that Bc cbs companies could avoid competing

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with 1 another for large contracts. A federal

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judge approved that settlement in 20 22.

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But later that year Home Depot and other

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Lit filed a challenge to the agreement, arguing

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that the settlement did not achieve the lawsuits

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original objective. Which was to stop Bc cbs

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companies from receiving exclusive geographic branding rights. A

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Circuit court of appeals upheld the settled in

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20 23 and Home Depot appealed to the

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supreme court in March of 20 24.

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We'll post acute care provider accent care has

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named Chris Main as president of its home

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health division. Mister Main had been with Opt

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since 20 14, and hem most recently served

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as president of the company's California business. His

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prior roles at Opt California included chief administrative

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officer and Coo. And prior to Opt, he

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spent 10 years with Da, which was purchased

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by Opt in 20 19.

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Other executive, big moves, B Wynn has been

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named president of Carol On health, the health

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services arm of El Health. Miss Wayne has

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been with El since 20 20. And before

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that, she was chief strategy and innovation officer

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at Bc of North Carolina.

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Caroline was launched in 20 22 when Anthem

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rebranded to El,

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consolidating the company's portfolio of Non insurance capabilities

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and services

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under a single name.

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And finally, Arkansas attorney general, Tim Griffin has

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filed a lawsuit against pharmacy benefit managers, opt

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and express scripts for their alleged role in

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enabling the opioid epidemic in the state. He

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He said, quote, pill by pill and dollar

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by dollar, Pb enabled the opioid epidemic in

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Arkansas. Today, we begin the process of holding

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them accountable for their roles in a crisis.

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That has ravaged our state, a crisis they

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helped cause contributed to and further. The lawsuit

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alleges that the United Health and Cy that

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subsidiaries, increased opioid use by placing opioids on

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lower formula tiers. They operated online retail pharmacies

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that dispensed morphine milligram equivalents of opioids and

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that they were aware of the epidemic, but

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they failed to act. Now a spokesperson for

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opt told back ers that Opt did not

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cause the opioid crisis or make it worse

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and that the company will defend itself in

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this litigation up takes the opioid epidemic seriously

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and has taken a comprehensive

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approach to fight this issue. A specific amount

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of damages isn't being sought in the lawsuit,

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but the attorney general is asking for full

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restitution to the state, and an abatement of

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the alleged public nuisance that was created.

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If you like the latest health insurance industry

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news delivered a straight inbox every morning. Subscribe

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to the Becker payer issues e news letter

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