This is Jacob Emerson with the Becker's Payer
Issues podcast. Here's your biweekly industry news briefing
for September 16th.
The National Committee For Quality Assurance has named
the best rated health plans of 2024
based on nearly fifty factors that include patient
experience and clinical quality.
The ratings were released September 16th and are
based on 2023 data from commercial, Medicare, Medicaid,
and ACA plans that reported HEDIS and CAHPS
results to the NCQA,
NCQA, which cover more than 227,000,000
people nationally.
NCQA accreditation status was also factored in. Plans
were rated on a 0 to 5 star
scale with 5 being the highest rating. And
in total, just over a 1000 plans received
a rating nationally. No Medicaid plan received 5
stars this year. Last year, 2 health plans
overall received 5 stars.
In terms of commercial plans that received a
5 star rating, that went to BCBS Massachusetts,
Independent Health Association out of New York, and
Kaiser's Mid Atlantic Health Plans, which is Washington
DC, Maryland, and Virginia.
And then 2 Medicare Advantage Plans received a
5 star rating as well. That went to
Kaiser's health plan in Colorado
and Froedtert Health's network health insurance
corporation in Wisconsin.
Well, Florida's insurance commissioner has given the green
light for health care service corporation to purchase
Cigna's Medicare business in the state. On September
11th, insurance commissioner of Florida signed a consent
order approving the indirect acquisition of Cigna's HealthSpring
of Florida by HCSC, which is the parent
company of 5 Blue Cross Blue Shield plans.
The Cigna Group reached a deal in January
to sell its Medicare business to HCSC for
$3,300,000,000.
The pending sale includes Cigna's Medicare Advantage, supplemental
benefits, Medicare Part d offerings, and Care Allies,
a value based care management subsidiary.
The deal will nearly quadruple HCSC's Medicare Advantage
membership. In January,
HCSC had just over 217,000
MA members. Cigna has just under 600,000
MA members, which is a small share of
its 19,000,000 total insurance customers.
The company also has 450,000
supplement members and 2 and a half 1000000
people
under Part d plans.
Well, Centene's Fidelis Care has reached a $7,600,000
settlement agreement with New York's attorney general for
billing Medicaid for services provided by an individual
convicted of a crime. Managed care organizations
contracted with the state of New York are
required to terminate their relationships with any provider
excluded from the state's Medicaid program.
State and federal law also requires Fidelis to
conduct routine checks of those exclusion lists.
Fidelis billed Medicaid for patient services from February
2019 to July 2021
from a company owned by a social worker
that had previously lost his license in 2017
after being convicted of a misdemeanor for firing
a BB gun at a child.
Under the settlement, Fidelis will pay back more
than $7,600,000
in reimbursements to the state's Medicaid program.
The company has also agreed to perform routine
status checks of its contracts for providers excluded
from Medicaid
and terminate any relationships identified during those reviews.
Well, CMS is suspending new enrollment for a
Centene Medicare Advantage subsidiary in Missouri after the
company failed to meet the required medical loss
ratio for 3 years in a row. MA
plans are required to spend at least 85%
of the money they receive on patient care
and quality improvement.
If a company fails to meet that threshold
for 3 consecutive years, CMS can stop the
company from enrolling new beneficiaries.
WellCare of Missouri, owned by Centene,
reported the following MLRs for its Medicare Advantage
prescription drug plan. It's just under 79%
in 2021.
It was 77.7%
in 2022,
and it was 84%
in 2023.
Because of that WellCare of Missouri will not
be allowed to enroll new members in its
MA prescription drug plan in 2025,
and it will be removed as an option
during the upcoming enrollment period.
WellCare must also ensure that all communications and
marketing materials clearly state that it is not
accepting new members
for next year. If the company reports an
MLR of at least 85%
this year, it may be allowed to enroll
new members again in 2026.
If not, the suspension will continue, and CMS
could terminate the contract entirely.
While Anthem Blue Cross Blue Shield is requesting
payments from some providers, it alleges falsified patients'
medical records when prescribing Ozempic.
That's according to a new report from Bloomberg.
A spokesperson for Elavance Health, which owns the
Anthem plans, told Bloomberg it contacted a small
number of providers about repayments for Ozempic prescribed
to their patients.
In some cases, the amount of repayment requested
was more than $1,000,000
Representatives for Elavance told Bloomberg that Anthem only
covers Ozempic for patients with type 2 diabetes.
The drug is not approved by the FDA
for weight loss, but it is often prescribed
off label for that purpose.
Wegovy, which contains the same active ingredient as
Ozempic,
is also approved for weight loss.
Last year, Anthem sent a small number of
providers letters indicating that off label use of
diabetes drugs is, quote, at an all time
high.
In those letters, Anthem told providers that falsifying
medical records in order to secure insurance coverage
of a drug is health care fraud.
One consultant told Bloomberg that the request for
the payment from providers was, quote, highly unusual.
And as the providers did not receive reimbursement
for the drugs, the pharmacies that dispense the
drugs would have been paid by insurers.
Well, UnitedHealthcare
and Humana are expected to collectively
receive 50% of the total Medicare Advantage Star
bonus payments being distributed in 2024,
while Kaiser Permanente is expected to collect the
highest average bonus per enrollee at $516.
That's according to a new analysis from KFF.
Total MA star ratings bonus payments increased by
more than 400%
between 2015
and 2023,
though those payments will decline by 8% to
$11,800,000,000
in 2024.
Total spending on MA bonuses is still higher
this year than in every year between 2015
and 2022.
UnitedHealthcare
is expected to receive 3,400,000,000,
Humana, 2a half 1000000. All other insurers, which
includes companies with less than 2% of total
MA enrollment nationally, are collectively going to receive
$2,100,000,000.
BCBS plans, which do include Elavance plans, are
going to receive 1,700,000,000.
CVS's Aetna will get 1,100,000,000.
Kaiser Permanente will get 976,000,000,
and Centene will receive 35,000,000.
And finally, administrative costs now account for more
than 40% of hospitals'
total expenses for delivering patient care with a
significant portion of that driven by the rising
number of care denials stemming from the growing
use of artificial intelligence tools by insurers.
Between 2022 and 2023,
claims denials surged by an average of 20.2%
for all commercial plans and by over 55%
for Medicare Advantage Plans according to the American
Hospital Association.
The wrote that one factor driving this growth
is the increased use of machine learning algorithms
and other artificial
intelligence tools. Poor applications of these technologies can
result in automatic denials of care without consideration
of a patient's individual clinical circumstances or review
from a clinician or plan medical director as
required.
And although the 2024 MA final rule did
provide some guidance around payment denials and practices,
the
emphasized that AI driven denials remains a serious
issue.
In its guidance earlier this year, CMS raised
concerns about the potential for AI tools to
perpetuate discrimination and bias.
The agency wrote in February that they are
concerned that algorithms and many new AI technologies
can exacerbate discrimination
and bias.
The agency advised that before implementing AI tools,
insurers must ensure that they do not reinforce
existing biases or introduce new ones.
Scrutiny of AI use by insurers has intensified
in recent years. UnitedHealthcare,
Humana, and Cigna are all facing lawsuits
alleging they wrongfully denied care to Medicare Advantage
members using AI algorithms.
As software technologies evolve rapidly, CMS has sought
to clarify the distinction between algorithms and AI.
It's also clarified
coverage requirements for payers when using algorithms and
other AI technologies.
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