This is Jacob Emerson with the Becker's Payer
Issues podcast.
Here's your industry news briefing for October 28th.
UnitedHealth Group representatives are set to meet with
Justice Department officials to make the case for
the company's acquisition of Amedisys to be approved.
That meeting is often the last step before
the DOJ decides whether to file a lawsuit
challenging an acquisition.
Amedisys provides home health, hospice, and high acuity
care. It operates more than 500 facilities across
37
states. Amedis' shareholders approved that acquisition back in
September of 2023.
The deal has been held up by regulatory
scrutiny. DOJ officials are concerned the deal could
increase prices for home health services.
UnitedHealth also acquired LHC Group, a home health
provider with more than 900 locations
back in February 2023.
If the acquisition of Amedisys is approved, the
company would own 10% of the home health
market, UnitedHealth that is, with significant overlap between
Amedisys and LHC Acquisitions in some southern states.
Regulators could approve the deal with some changes
to address competition concerns.
In August, Amedisys and UnitedHealth agreed to sell
an undisclosed number of care center care centers
to Vital Caring Group if the merger is
approved.
Well, Medicare Advantage companies are bringing in 1,000,000,000
in questionable payments found during in home visits
and chart reviews. That's according to HHS's office
of inspector general in a new audit. That
report was published October 24th, and the federal
watchdog estimated that MA companies received 7 and
a half $1,000,000,000
in payments through health risk assessments and chart
reviews.
The watchdog wrote that questionable use of HRAs
is driving up payments to plans.
MA plans conduct HRAs to collect information about
enrollee health status.
These assessments are sometimes conducted by providers as
part of beneficiaries
annual wellness visits or in their homes. MA
plans also conduct
chart reviews to find diagnoses that may have
been missed by providers during visits.
CMS found that 1,700,000
Medicare Advantage enrollees with diagnoses from HRAs and
chart reviews
were not substantiated
by any other
visits, procedures, or tests in their medical records.
Diagnoses reported only on an HRA conducted at
any setting, but on no other service records,
raise questions about whether the diagnoses are valid
and whether enrollees got needed care according to
the reports.
UnitedHealth Group stood out from its peers in
its in in its use of in home
visits and chart reviews to generate payments according
to the OIG.
United is also the largest Medicare Advantage provider
and receives $3,700,000,000
in risk adjustment payments from HRAs and chart
reviews in 2023.
In a statement shared with Becker's, a UnitedHealthcare
spokesperson said that the report is a misleading,
narrow, and incomplete view of risk adjustment data
and is being used to draw inaccurate conclusions
about the value of in home care for
MA beneficiaries.
Well, Kodiak Solutions says that its analysis of
hospital inpatient and outpatient claims data suggests that
payers are, quote, continuing to apply their own
criteria for inpatient admissions
and dismissing the 2 midnight rule for Medicare
beneficiaries.
The firm analyzed claims data for more than
1900 hospitals between July 2023
June 2024.
The analysis compares observation rates prior to and
following the January 2024 implementation
of the 2 midnight rule for Medicare Advantage
plans.
Kodiak analyzed data for 3 health plan categories,
commercial, Medicare Advantage, and traditional Medicare.
The data showed that ma plans began classifying
fewer observation stays starting in January
observation rates for ma plans ranged between 18%
20% of claims in the last 6 months
of last year and then fluctuated with a
lower range of 14%
16%
in the 6 1st 6 months of this
year.
Observation rates in traditional Medicare also trended down
over the 12 month period but within a
range of 5.2 to 3.7 percent with the
exception of a spike to 8 a half
percent in December.
According to Kodiak, the gap in observation rates
between MA plans and traditional Medicare suggest that
MA plans are not fully complying with the
federal rule requiring them to offer members the
same coverage as traditional Medicare. Our data shows
that MA observation rates are similar to the
rates among patients covered by commercial insurance. And,
of course, most of the MA plans are
also providers of commercial insurance.
Well, Centene is the latest insurer challenging CMS'
star ratings in court. In a lawsuit filed
October 22nd, Centene asked a federal judge to
require CMS to calculate recalculate its star ratings
without including a secret shopper phone call. Centene
says never reached its call centers. C Mass
conducts secret shopper's
calls to score plans' customer service functions, including
text to voice services.
These services are often used by individuals with
hearing or speech disabilities.
In its lawsuit, Centene alleged the agency included
a call that never reached its call center
due to no fault of its own Centene
alleged the secret shopper's notes show that the
chat window closed unexpectedly
which Centene called
a clear failure of CMS's
software
star ratings determine whether plans are eligible for
bonus payments from CMS the inclusion of the
call in its rating will cause Centene to
lose out on $73,000,000
in revenue according to the company
several other insurers have challenged CMS's star ratings
in court this year UnitedHealthcare
also
disputed the inclusion of a secret shopper phone
call it says never connected to its call
center
well UnitedHealth Group has reached a settlement with
the US Department of Labor over allegations that
the company improperly denied claims for emergency room
visits and urinary drug screenings for thousands of
patients.
The final settlement amount is unclear, but that
order was signed October 21st in a Wisconsin
federal court. The Labor Department originally filed its
lawsuit against UnitedHealth
subsidiary,
UMR, in July 2023.
UMR is UnitedHealthcare's
third party administrator that provides health benefits services
to more than 21100
self funded employer plans.
By denying emergency claims quote based solely on
diagnosis codes and not implying a prudent layperson
standard, the government said that UMR violated
e ERISA
which oversees
self funded plans. The department added that UMR's
explanation to members for the denied emergency claims
violated the ACA and the government's internal claims
procedures regulations.
For urinary test denials, the labor department alleged
that UMR denied all claims from August 20
15 to August 2018
without determining whether a claim was medically necessary.
The lawsuit had sought to require UMR to
reform its emergency and urinary drug testing claims
procedures
to comply with ERISA and re adjudicate all
denied or partially denied claims from January 1,
2015
to the present day.
Wall Street analysts say that a potential Cigna
Humana merger depends on the results of the
presidential election.
Bloomberg reported on October 18th that Cigna and
Humana had resumed merger discussions.
They were in talks to merge in late
2023, but the deal fell apart over a
disagreement on price.
One analyst with wrote said told Bloomberg that
the merger would only tangibly move forward if
Republican nominee Donald Trump wins in November. If
Humana and Cigna merge, it would create one
of the largest health care companies in the
US
and certainly draw antitrust to scrutiny.
Under current FTC chair, Lena Khan's leadership, at
least 7 major health care deals have been
blocked.
A second Trump administration could take a more
permissive view towards m and a. The administration
approved CVS Health's $69,000,000,000
acquisition of Aetna in 2018.
And finally, Elevance Health is laying off a
123 employees in Southern California.
Elevance will lay off 59 employees at Anthem
Blue Cross in Woodland Hills and 64 employees
at a Carillon office in in Cerritos.
Last October, CEO Gail Boudreaux said the company
took about $700,000,000
in charges due to workforce adjustments and technology
asset write offs during a strategic review. Since
then, the company has laid off 90 employees
at a facility in Dearborn, Michigan, 87 other
employees in Woodland Hills, and 57 workers at
a facility in Minnesota.
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