A Senate report shows that UnitedHealth Group (UHG), the parent company to the nation's and Arizona's largest Medicare Advantage (MA) insurer, UnitedHealthcare (UHC), is artificially inflating the risk adjustment scores of its MA members in order to achieve higher reimbursement from the Medicare program.
The report is based on 50,000...
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) announced last month that it would investigate the use of prior authorization in denials for post-acute care by Medicare Advantage plans.
In the new audit, OIG plans to look into processes for reviewing prior authorization requests for post-acute...
Medicare Advantage insurers are struggling to maintain strong projections of growth following the news of very meager reimbursement rate reductions.
The Centers for Medicare and Medicaid Services (CMS) anticipates that the 0.16% reduction in the MA benchmark rate in 2025 will come as an effect of modifications to the diagnostic coding...National News
Humana has filed suit against the Centers for Medicare and Medicaid Services (CMS) for a rule announced earlier this year that would allow the government to recoup overpayments from insurers based on extrapolated audits. Also, Novartis has challenged the Biden administration over the Medicare Drug Price Negotiation rule.
Studies have...National News
The Medicare system is on a crash course toward insolvency, and the evidence is mounting that overpayments to Medicare Advantage plans and the use of pharmacy benefit managers (PBMs) are responsible for a great deal of those overpayments.
Two researchers, Steven Lieberman and Paul Ginsberg, Ph.D, published a study earlier this year...
Published Friday, the rate notice includes a 3.32% overall pay raise which was up from the 1.03% in the proposed rule.
The Centers for Medicare and Medicaid Services (CMS) appears to have ceded to the demands of the insurance industry; the new pay rates translate to a $13.8 billion increase for insurers, according to Axios, CMS will...
The atmosphere around the future of Medicare Advantage has been fraught since the announcement of the final rule on Risk Adjustment Data Validation (RADV).
The rule's new methodology will be applied to plans dating back to 2018, and the Centers for Medicare and Medicaid Services (CMS) anticipates it will recoup nearly $50 billion for...
The Centers for Medicare and Medicaid Services (CMS) has issued a final rule that will increase the amount federal authorities can recoup from Medicare Advantage organizations (MAOs) that were overpaid due to incorrect diagnostic coding.
The Medicare Risk Adjustment Data Validation (RADV) final rule means that CMS will also stop...
Medicare Advantage officially has 30 million enrollees. But with great patient volume comes great responsibility according to the Centers for Medicare and Medicaid Services (CMS), which has pledged tougher audits while finalizing tougher rules for MA plans.
The announcement that MA had crossed the 30 million enrollees mark was made...
Medicare Advantage enrollees who use insulin may not know the insulin cost cap limits all monthly out-of-pocket costs for insulin to $35 -- and that could influence how they select their Medicare Advantage plans during the open enrollment period.
For the current open enrollment period, the insulin cost cap was not factored into the...National News
As the Biden administration promised, the U.S. Department of Health Services (HHS) Office of Inspector General (OIG) is sifting through claims submitted by Medicare Advantage (MA) plans, looking for fraudulent activity.
The OIG published two audits this week on Medicare Advantage Compliance of diagnostic codes submitted to the Centers...
Last week, the Centers for Medicare and Medicaid Services (CMS) released a Request for Information (RFI), seeking comment on ways to improve Medicare Advantage and make the program more equitable, affordable and sustainable.
Medicare Advantage (MA) has been under great scrutiny lately, for policies on prior authorization, the adequacy...
Last Wednesday, the Centers for Medicare and Medicaid Services (CMS) announced proposed payment policy changes for the Medicare Advantage and Part D programs for Calendar Year (CY) 2023. The proposal includes a 7.98% payment increase and health equity provisions for MA participation, for example in star ratings.
The advance notice was...
