1 00:00:00,080 --> 00:00:02,319 This is Jacob Emerson with the Becker's Payer 2 00:00:02,319 --> 00:00:06,019 Issues podcast. Here's your biweekly industry news briefing 3 00:00:06,080 --> 00:00:07,620 for September 16th. 4 00:00:08,160 --> 00:00:11,039 The National Committee For Quality Assurance has named 5 00:00:11,039 --> 00:00:12,900 the best rated health plans of 2024 6 00:00:13,199 --> 00:00:15,984 based on nearly fifty factors that include patient 7 00:00:15,984 --> 00:00:17,765 experience and clinical quality. 8 00:00:18,224 --> 00:00:20,464 The ratings were released September 16th and are 9 00:00:20,464 --> 00:00:23,585 based on 2023 data from commercial, Medicare, Medicaid, 10 00:00:23,585 --> 00:00:26,384 and ACA plans that reported HEDIS and CAHPS 11 00:00:26,384 --> 00:00:27,359 results to the NCQA, 12 00:00:27,920 --> 00:00:29,539 NCQA, which cover more than 227,000,000 13 00:00:30,320 --> 00:00:31,060 people nationally. 14 00:00:31,519 --> 00:00:35,440 NCQA accreditation status was also factored in. Plans 15 00:00:35,440 --> 00:00:37,520 were rated on a 0 to 5 star 16 00:00:37,520 --> 00:00:40,024 scale with 5 being the highest rating. And 17 00:00:40,024 --> 00:00:42,585 in total, just over a 1000 plans received 18 00:00:42,585 --> 00:00:45,704 a rating nationally. No Medicaid plan received 5 19 00:00:45,704 --> 00:00:48,344 stars this year. Last year, 2 health plans 20 00:00:48,344 --> 00:00:50,045 overall received 5 stars. 21 00:00:50,585 --> 00:00:52,890 In terms of commercial plans that received a 22 00:00:52,890 --> 00:00:55,549 5 star rating, that went to BCBS Massachusetts, 23 00:00:56,009 --> 00:00:59,129 Independent Health Association out of New York, and 24 00:00:59,129 --> 00:01:02,250 Kaiser's Mid Atlantic Health Plans, which is Washington 25 00:01:02,250 --> 00:01:03,789 DC, Maryland, and Virginia. 26 00:01:04,329 --> 00:01:06,489 And then 2 Medicare Advantage Plans received a 27 00:01:06,489 --> 00:01:08,204 5 star rating as well. That went to 28 00:01:08,204 --> 00:01:09,984 Kaiser's health plan in Colorado 29 00:01:10,444 --> 00:01:13,185 and Froedtert Health's network health insurance 30 00:01:13,564 --> 00:01:15,185 corporation in Wisconsin. 31 00:01:17,325 --> 00:01:19,484 Well, Florida's insurance commissioner has given the green 32 00:01:19,484 --> 00:01:21,965 light for health care service corporation to purchase 33 00:01:21,965 --> 00:01:24,500 Cigna's Medicare business in the state. On September 34 00:01:24,500 --> 00:01:27,700 11th, insurance commissioner of Florida signed a consent 35 00:01:27,700 --> 00:01:30,819 order approving the indirect acquisition of Cigna's HealthSpring 36 00:01:30,819 --> 00:01:33,459 of Florida by HCSC, which is the parent 37 00:01:33,459 --> 00:01:35,719 company of 5 Blue Cross Blue Shield plans. 38 00:01:35,859 --> 00:01:37,715 The Cigna Group reached a deal in January 39 00:01:37,715 --> 00:01:39,954 to sell its Medicare business to HCSC for 40 00:01:39,954 --> 00:01:40,454 $3,300,000,000. 41 00:01:41,795 --> 00:01:45,495 The pending sale includes Cigna's Medicare Advantage, supplemental 42 00:01:45,555 --> 00:01:49,015 benefits, Medicare Part d offerings, and Care Allies, 43 00:01:49,155 --> 00:01:51,255 a value based care management subsidiary. 44 00:01:51,730 --> 00:01:55,090 The deal will nearly quadruple HCSC's Medicare Advantage 45 00:01:55,090 --> 00:01:56,469 membership. In January, 46 00:01:56,849 --> 00:01:59,269 HCSC had just over 217,000 47 00:01:59,969 --> 00:02:02,790 MA members. Cigna has just under 600,000 48 00:02:03,250 --> 00:02:05,084 MA members, which is a small share of 49 00:02:05,084 --> 00:02:07,584 its 19,000,000 total insurance customers. 50 00:02:08,044 --> 00:02:09,504 The company also has 450,000 51 00:02:10,044 --> 00:02:11,965 supplement members and 2 and a half 1000000 52 00:02:11,965 --> 00:02:12,465 people 53 00:02:12,764 --> 00:02:14,305 under Part d plans. 54 00:02:15,884 --> 00:02:18,544 Well, Centene's Fidelis Care has reached a $7,600,000 55 00:02:19,490 --> 00:02:21,969 settlement agreement with New York's attorney general for 56 00:02:21,969 --> 00:02:24,629 billing Medicaid for services provided by an individual 57 00:02:24,689 --> 00:02:27,270 convicted of a crime. Managed care organizations 58 00:02:27,569 --> 00:02:29,330 contracted with the state of New York are 59 00:02:29,330 --> 00:02:31,969 required to terminate their relationships with any provider 60 00:02:31,969 --> 00:02:34,230 excluded from the state's Medicaid program. 61 00:02:34,605 --> 00:02:36,844 State and federal law also requires Fidelis to 62 00:02:36,844 --> 00:02:40,145 conduct routine checks of those exclusion lists. 63 00:02:40,605 --> 00:02:44,465 Fidelis billed Medicaid for patient services from February 64 00:02:44,605 --> 00:02:46,224 2019 to July 2021 65 00:02:46,860 --> 00:02:48,939 from a company owned by a social worker 66 00:02:48,939 --> 00:02:51,280 that had previously lost his license in 2017 67 00:02:51,900 --> 00:02:54,219 after being convicted of a misdemeanor for firing 68 00:02:54,219 --> 00:02:56,000 a BB gun at a child. 69 00:02:56,379 --> 00:02:58,379 Under the settlement, Fidelis will pay back more 70 00:02:58,379 --> 00:02:59,039 than $7,600,000 71 00:02:59,819 --> 00:03:02,159 in reimbursements to the state's Medicaid program. 72 00:03:02,574 --> 00:03:04,914 The company has also agreed to perform routine 73 00:03:04,974 --> 00:03:07,854 status checks of its contracts for providers excluded 74 00:03:07,854 --> 00:03:08,594 from Medicaid 75 00:03:08,894 --> 00:03:12,114 and terminate any relationships identified during those reviews. 76 00:03:13,775 --> 00:03:16,009 Well, CMS is suspending new enrollment for a 77 00:03:16,009 --> 00:03:19,129 Centene Medicare Advantage subsidiary in Missouri after the 78 00:03:19,129 --> 00:03:21,209 company failed to meet the required medical loss 79 00:03:21,209 --> 00:03:23,769 ratio for 3 years in a row. MA 80 00:03:23,769 --> 00:03:25,949 plans are required to spend at least 85% 81 00:03:26,090 --> 00:03:28,110 of the money they receive on patient care 82 00:03:28,395 --> 00:03:29,534 and quality improvement. 83 00:03:29,995 --> 00:03:31,914 If a company fails to meet that threshold 84 00:03:31,914 --> 00:03:34,395 for 3 consecutive years, CMS can stop the 85 00:03:34,395 --> 00:03:36,334 company from enrolling new beneficiaries. 86 00:03:37,194 --> 00:03:39,694 WellCare of Missouri, owned by Centene, 87 00:03:40,155 --> 00:03:43,034 reported the following MLRs for its Medicare Advantage 88 00:03:43,034 --> 00:03:46,150 prescription drug plan. It's just under 79% 89 00:03:46,450 --> 00:03:47,189 in 2021. 90 00:03:47,650 --> 00:03:48,469 It was 77.7% 91 00:03:49,409 --> 00:03:50,150 in 2022, 92 00:03:50,450 --> 00:03:51,430 and it was 84% 93 00:03:51,889 --> 00:03:52,629 in 2023. 94 00:03:53,490 --> 00:03:55,730 Because of that WellCare of Missouri will not 95 00:03:55,730 --> 00:03:57,490 be allowed to enroll new members in its 96 00:03:57,490 --> 00:03:59,430 MA prescription drug plan in 2025, 97 00:04:00,004 --> 00:04:01,284 and it will be removed as an option 98 00:04:01,284 --> 00:04:02,985 during the upcoming enrollment period. 99 00:04:03,284 --> 00:04:05,925 WellCare must also ensure that all communications and 100 00:04:05,925 --> 00:04:08,724 marketing materials clearly state that it is not 101 00:04:08,724 --> 00:04:09,865 accepting new members 102 00:04:10,245 --> 00:04:12,324 for next year. If the company reports an 103 00:04:12,324 --> 00:04:13,784 MLR of at least 85% 104 00:04:14,085 --> 00:04:16,310 this year, it may be allowed to enroll 105 00:04:16,310 --> 00:04:17,769 new members again in 2026. 106 00:04:18,389 --> 00:04:20,649 If not, the suspension will continue, and CMS 107 00:04:20,789 --> 00:04:22,970 could terminate the contract entirely. 108 00:04:24,550 --> 00:04:26,629 While Anthem Blue Cross Blue Shield is requesting 109 00:04:26,629 --> 00:04:29,745 payments from some providers, it alleges falsified patients' 110 00:04:29,805 --> 00:04:32,225 medical records when prescribing Ozempic. 111 00:04:32,605 --> 00:04:34,944 That's according to a new report from Bloomberg. 112 00:04:35,404 --> 00:04:37,884 A spokesperson for Elavance Health, which owns the 113 00:04:37,884 --> 00:04:41,004 Anthem plans, told Bloomberg it contacted a small 114 00:04:41,004 --> 00:04:43,964 number of providers about repayments for Ozempic prescribed 115 00:04:43,964 --> 00:04:45,050 to their patients. 116 00:04:45,350 --> 00:04:47,509 In some cases, the amount of repayment requested 117 00:04:47,509 --> 00:04:48,970 was more than $1,000,000 118 00:04:49,430 --> 00:04:52,149 Representatives for Elavance told Bloomberg that Anthem only 119 00:04:52,149 --> 00:04:54,649 covers Ozempic for patients with type 2 diabetes. 120 00:04:55,110 --> 00:04:57,029 The drug is not approved by the FDA 121 00:04:57,029 --> 00:04:58,889 for weight loss, but it is often prescribed 122 00:04:59,055 --> 00:05:00,435 off label for that purpose. 123 00:05:00,894 --> 00:05:03,454 Wegovy, which contains the same active ingredient as 124 00:05:03,454 --> 00:05:03,954 Ozempic, 125 00:05:04,254 --> 00:05:06,194 is also approved for weight loss. 126 00:05:06,574 --> 00:05:08,574 Last year, Anthem sent a small number of 127 00:05:08,574 --> 00:05:11,214 providers letters indicating that off label use of 128 00:05:11,214 --> 00:05:13,379 diabetes drugs is, quote, at an all time 129 00:05:13,379 --> 00:05:13,879 high. 130 00:05:14,259 --> 00:05:16,839 In those letters, Anthem told providers that falsifying 131 00:05:16,899 --> 00:05:19,860 medical records in order to secure insurance coverage 132 00:05:19,860 --> 00:05:22,120 of a drug is health care fraud. 133 00:05:23,699 --> 00:05:26,100 One consultant told Bloomberg that the request for 134 00:05:26,100 --> 00:05:28,654 the payment from providers was, quote, highly unusual. 135 00:05:28,654 --> 00:05:30,754 And as the providers did not receive reimbursement 136 00:05:30,814 --> 00:05:32,975 for the drugs, the pharmacies that dispense the 137 00:05:32,975 --> 00:05:34,834 drugs would have been paid by insurers. 138 00:05:37,134 --> 00:05:37,954 Well, UnitedHealthcare 139 00:05:38,334 --> 00:05:40,355 and Humana are expected to collectively 140 00:05:40,759 --> 00:05:43,560 receive 50% of the total Medicare Advantage Star 141 00:05:43,560 --> 00:05:45,819 bonus payments being distributed in 2024, 142 00:05:46,279 --> 00:05:48,680 while Kaiser Permanente is expected to collect the 143 00:05:48,680 --> 00:05:51,500 highest average bonus per enrollee at $516. 144 00:05:52,774 --> 00:05:55,435 That's according to a new analysis from KFF. 145 00:05:55,975 --> 00:05:58,615 Total MA star ratings bonus payments increased by 146 00:05:58,615 --> 00:05:59,435 more than 400% 147 00:05:59,814 --> 00:06:00,634 between 2015 148 00:06:01,014 --> 00:06:01,595 and 2023, 149 00:06:02,134 --> 00:06:04,455 though those payments will decline by 8% to 150 00:06:04,455 --> 00:06:04,955 $11,800,000,000 151 00:06:05,895 --> 00:06:06,634 in 2024. 152 00:06:07,339 --> 00:06:10,139 Total spending on MA bonuses is still higher 153 00:06:10,139 --> 00:06:12,479 this year than in every year between 2015 154 00:06:12,860 --> 00:06:13,439 and 2022. 155 00:06:16,379 --> 00:06:16,879 UnitedHealthcare 156 00:06:17,180 --> 00:06:18,720 is expected to receive 3,400,000,000, 157 00:06:19,419 --> 00:06:22,634 Humana, 2a half 1000000. All other insurers, which 158 00:06:22,634 --> 00:06:25,035 includes companies with less than 2% of total 159 00:06:25,035 --> 00:06:27,595 MA enrollment nationally, are collectively going to receive 160 00:06:27,595 --> 00:06:28,095 $2,100,000,000. 161 00:06:29,435 --> 00:06:32,475 BCBS plans, which do include Elavance plans, are 162 00:06:32,475 --> 00:06:33,774 going to receive 1,700,000,000. 163 00:06:34,699 --> 00:06:36,959 CVS's Aetna will get 1,100,000,000. 164 00:06:37,579 --> 00:06:39,839 Kaiser Permanente will get 976,000,000, 165 00:06:40,620 --> 00:06:42,560 and Centene will receive 35,000,000. 166 00:06:44,300 --> 00:06:47,180 And finally, administrative costs now account for more 167 00:06:47,180 --> 00:06:48,639 than 40% of hospitals' 168 00:06:48,944 --> 00:06:51,745 total expenses for delivering patient care with a 169 00:06:51,745 --> 00:06:54,704 significant portion of that driven by the rising 170 00:06:54,704 --> 00:06:57,024 number of care denials stemming from the growing 171 00:06:57,024 --> 00:06:59,925 use of artificial intelligence tools by insurers. 172 00:07:00,464 --> 00:07:02,164 Between 2022 and 2023, 173 00:07:02,544 --> 00:07:05,100 claims denials surged by an average of 20.2% 174 00:07:05,879 --> 00:07:08,779 for all commercial plans and by over 55% 175 00:07:09,319 --> 00:07:12,439 for Medicare Advantage Plans according to the American 176 00:07:12,439 --> 00:07:13,420 Hospital Association. 177 00:07:14,040 --> 00:07:16,600 The wrote that one factor driving this growth 178 00:07:16,600 --> 00:07:19,254 is the increased use of machine learning algorithms 179 00:07:19,314 --> 00:07:20,055 and other artificial 180 00:07:20,435 --> 00:07:24,194 intelligence tools. Poor applications of these technologies can 181 00:07:24,194 --> 00:07:27,175 result in automatic denials of care without consideration 182 00:07:27,314 --> 00:07:30,294 of a patient's individual clinical circumstances or review 183 00:07:30,354 --> 00:07:32,709 from a clinician or plan medical director as 184 00:07:32,709 --> 00:07:33,209 required. 185 00:07:33,750 --> 00:07:36,709 And although the 2024 MA final rule did 186 00:07:36,709 --> 00:07:39,529 provide some guidance around payment denials and practices, 187 00:07:39,909 --> 00:07:40,409 the 188 00:07:40,870 --> 00:07:43,909 emphasized that AI driven denials remains a serious 189 00:07:43,909 --> 00:07:44,409 issue. 190 00:07:44,789 --> 00:07:47,314 In its guidance earlier this year, CMS raised 191 00:07:47,314 --> 00:07:49,714 concerns about the potential for AI tools to 192 00:07:49,714 --> 00:07:51,894 perpetuate discrimination and bias. 193 00:07:52,355 --> 00:07:54,355 The agency wrote in February that they are 194 00:07:54,355 --> 00:07:57,095 concerned that algorithms and many new AI technologies 195 00:07:57,475 --> 00:07:58,774 can exacerbate discrimination 196 00:07:59,074 --> 00:07:59,735 and bias. 197 00:08:00,560 --> 00:08:04,099 The agency advised that before implementing AI tools, 198 00:08:04,160 --> 00:08:06,660 insurers must ensure that they do not reinforce 199 00:08:06,959 --> 00:08:09,779 existing biases or introduce new ones. 200 00:08:10,240 --> 00:08:13,634 Scrutiny of AI use by insurers has intensified 201 00:08:13,774 --> 00:08:15,314 in recent years. UnitedHealthcare, 202 00:08:15,774 --> 00:08:18,194 Humana, and Cigna are all facing lawsuits 203 00:08:18,654 --> 00:08:21,295 alleging they wrongfully denied care to Medicare Advantage 204 00:08:21,295 --> 00:08:22,995 members using AI algorithms. 205 00:08:23,535 --> 00:08:26,910 As software technologies evolve rapidly, CMS has sought 206 00:08:26,910 --> 00:08:30,129 to clarify the distinction between algorithms and AI. 207 00:08:31,310 --> 00:08:32,529 It's also clarified 208 00:08:32,990 --> 00:08:36,350 coverage requirements for payers when using algorithms and 209 00:08:36,350 --> 00:08:37,570 other AI technologies. 210 00:08:38,509 --> 00:08:40,350 If you like the latest health insurance industry 211 00:08:40,350 --> 00:08:42,434 news delivered straight to your inbox every morning, 212 00:08:42,434 --> 00:08:44,774 subscribe to the Becker's payer issues e newsletter 213 00:08:44,835 --> 00:08:46,534 on our websites at beckerspayer.com.