This is Jacob I sent with the Becker
payer issues podcast.
Here's your bi weekly industry news briefing for
June 20 sixth. Lawmakers are pushing Cms to
do more to prevent misuse of artificial intelligence
by Medicare advantage plans. A group of 51
lawmakers signed a letter to Cms administrator, Chi
Brooks asu on June 20 fifth.
Asking the agency to implement more stringent oversight
regarding the technology.
In November, families of 2 United health Medicare
advantage members sued the company, alleging that Nav
Health an Ai algorithm owned by Opt, wrongfully
denied the members post acute care. An Opt
spokesperson previously told backers that the product is
not used to make coverage
determinations. In their letter, the lawmakers wrote, they
remain concerned about M plans use of prior
authorization, specifically their ongoing use of artificial intelligence,
algorithm software to guide coverage decisions.
Plans continue to use Ai tools to erroneous
deny care and contradict to provider assessment findings.
In February, Cms published guidance on how Ai
can be used by M plans. In its
guidance, the agency said payers can use out
to support coverage decisions, but is their responsibility
to ensure that an algorithm or Ai based
tool is compliant with Cms requirements.
M plans can use algorithms only to predict
length of stay for post acute services, and
not as the basis for terminating coverage.
At a February hearing, experts told members of
the Senate Finance committee that Cms is guidance
may not be clear enough to prevent misuse
of.
In their letter, the lawmakers urged Cms to
implement more specific guidance around how plans can
use Ai. The legislators are asking the agency
to create an approval process. Us to vet
new Ai tools used by insurers and to
prohibit the use of Ai tools and coverage
decisions until the agency has completed Asus systematic
review.
Well Blue Shield of California has fired a
top executive for allegedly lying about her medical
credentials.
Tasha Lara La was previously the interim vice
president, Chief Medical Officer and the medical director
of medical management and accreditation, and Blue Shield.
The company told Backers, it has it had
learned a former employee, quote, misrepresented her name
and licensure, and so they reported the matter
to law enforcement.
Miss lara La is listed as a doctor
of os homeopathic medicine in an archived version
of blue builds corporate leadership page. There is
no record of her in the licensed date
In the licensing database of the Os path
Medical Board of California
The individual... She did not treat patients and
her role was primarily
administrative. The company told Becker that because this
is an active fraud investigation as well as
a personnel matter. They cannot discuss more details,
but they are confident the authorities will conduct
a thorough
investigation and they are committed to supporting that
effort.
Well the Us Supreme Court has declined to
hear Home Depot challenge to a 2670000000.00
up settlement with Blue Cross Blue Shield companies,
ending a legal saga over alleged and competitive
behavior the Dates valor back to 20 12.
The court also rejected a related challenge for
a 667000000
dollar fee award for the attorneys who were
involved with the settlement.
Now Bc cbs members first brought this case
back in 20 12, alleging that Bc cbs
companies conspired to divide up markets to avoid
competing with each other, thereby driving up costs
for consumers.
In 20 20, Bc cbs companies and the
Association reached that 2700000000.0
dollar settlement, in which Bc admitted to no
wrongdoing.
That settlement mandated the Bc companies drop an
association rule that required 2 thirds of national
net revenues from health plans and related services
to come from blue branded products.
Another rule, the settlement struck down had required
large employers to work with the blue insurer
that offers coverage where the employer is. Headquartered
so that Bc cbs companies could avoid competing
with 1 another for large contracts. A federal
judge approved that settlement in 20 22.
But later that year Home Depot and other
Lit filed a challenge to the agreement, arguing
that the settlement did not achieve the lawsuits
original objective. Which was to stop Bc cbs
companies from receiving exclusive geographic branding rights. A
Circuit court of appeals upheld the settled in
20 23 and Home Depot appealed to the
supreme court in March of 20 24.
We'll post acute care provider accent care has
named Chris Main as president of its home
health division. Mister Main had been with Opt
since 20 14, and hem most recently served
as president of the company's California business. His
prior roles at Opt California included chief administrative
officer and Coo. And prior to Opt, he
spent 10 years with Da, which was purchased
by Opt in 20 19.
Other executive, big moves, B Wynn has been
named president of Carol On health, the health
services arm of El Health. Miss Wayne has
been with El since 20 20. And before
that, she was chief strategy and innovation officer
at Bc of North Carolina.
Caroline was launched in 20 22 when Anthem
rebranded to El,
consolidating the company's portfolio of Non insurance capabilities
and services
under a single name.
And finally, Arkansas attorney general, Tim Griffin has
filed a lawsuit against pharmacy benefit managers, opt
and express scripts for their alleged role in
enabling the opioid epidemic in the state. He
He said, quote, pill by pill and dollar
by dollar, Pb enabled the opioid epidemic in
Arkansas. Today, we begin the process of holding
them accountable for their roles in a crisis.
That has ravaged our state, a crisis they
helped cause contributed to and further. The lawsuit
alleges that the United Health and Cy that
subsidiaries, increased opioid use by placing opioids on
lower formula tiers. They operated online retail pharmacies
that dispensed morphine milligram equivalents of opioids and
that they were aware of the epidemic, but
they failed to act. Now a spokesperson for
opt told back ers that Opt did not
cause the opioid crisis or make it worse
and that the company will defend itself in
this litigation up takes the opioid epidemic seriously
and has taken a comprehensive
approach to fight this issue. A specific amount
of damages isn't being sought in the lawsuit,
but the attorney general is asking for full
restitution to the state, and an abatement of
the alleged public nuisance that was created.
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