CMS bends to health plans' will on call center scoring. UnitedHealthcare, Centene and Humana have all sued the government this fall for downgrading their quality scores based on assessments of their customer support centers. This has impacted their Star Ratings and lowered their government compensation. But now CMS has announced it is revising the scoring emphasis on call centers. Click here. It doesn't mean that the plans will automatically receive higher scores now, but my bet is that the courts will side with the plans.
Q3 Earnings for Major Insurers Show Big Profits (but not as big as last year)The third quarter of 2024 produced mixed financial results for major insurers, with most seeing year-over-year profit declines, except for UnitedHealth and Centene, which posted gains. UnitedHealth led the pack with nearly $6.1 billion in profit, though its year-to-date earnings dropped significantly from 2023. Insurers like CVS Health and Humana faced profitability challenges, particularly from rising MA utilization and changes in star ratings. Meanwhile, Medicaid-related losses continued to impact Centene and Elevance Health, though both companies offset some of these declines in other segments. Click here to view the Q3 earnings reports.
The Cigna Group reaffirmed its financial outlook in a released statement on the full year 2024, projecting at least $28.40 in adjusted income per share and a 10 percent growth in earnings per share for 2025 and confirmed it is not pursuing a merger with Humana, amidst ongoing speculation, click here.
Report: MA Prior Authorization Usage Grew Considerably Since 2018Between 2018 and 2024, the percentage of Medicare Advantage enrollees subject to prior authorization significantly increased anywhere from 18 and 29 percentage points depending on the service area. Additionally, a new analysis by KNG Health Consulting shows that 99 percent of MA enrollees subject to PA for some services and there were more than 46 million PA requests (or 1.7 per MA enrollee), of which 7.4 percent were denied, in 2022 alone. A troubling issue that was observed by the researchers is that more than 80 percent of appeals were overturned by the MA plans, suggesting that some of the initial denials may have been inappropriate. To view the analysis, click here.
The Wall Street Journal highlights how MA plans are passing high health care costs to taxpayers when MA beneficiaries switch to Traditional Medicare toward the end of their lives, click here.
A new report investigates rising concerns about duplicative federal spending as MA veteran enrollments increase. MA plans receive full payments even when veterans primarily rely on Veterans Health Administration care. The report found that between 2016 and 2022, veteran enrollment in MA grew, including in plans where over 20 percent of enrollees were veterans, and among these "high-veteran" MA plans, one in five VHA enrollees used no Medicare-funded services - 2.5 times the rate in other MA plans and nearly six times that of the general MA population. Instead, these veterans were more likely to use VHA-funded care. Click here for the report.
In an editorial, Dr. Robert Devereaux reflects on his experience with "upcoding" in MA, a practice that inflates patient diagnoses to secure higher reimbursement rates from insurers. While initially seen as a harmless strategy to bolster departmental finances, he later learned that upcoding contributes to billions in Medicare overpayments annually. Click here to read the editorial.
ACO Program Saves CMS Hundreds of Millions, Association Wants ExtensionAccountable care organizations in the ACO Realizing Equity, Access and Community Health (ACO REACH) Model saved CMS hundreds of millions of dollars, prompting the National Association of ACOs (NAACOS) to advocate the program's extension. ACO Reach participants achieved $1.64 billion in gross savings for CMS and $694.6 million in net savings, the agency announced earlier this month. 132 REACH ACOs participated in the model in PY 2023. To view the statement from NAACOS, click here, and for more on the model from CMS, click here.
CMS to Host Leadership CallAs the leadership at CMS is set to change in a couple of months with the new Administration, the agency has scheduled a call to "discuss CMS' accomplishments and express our thanks to you, our partners, for helping us to implement our Strategic Plan and key initiatives over the past several years." The call is on Wednesday, November 20, 2024, at 2:00 ET and will feature CMS Administrator, Chiquita Brooks-LaSure, and her leadership team. To RSVP for the call, click here.
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