On June 15, 2022, the Supreme Court issued a unanimous ruling in American Hospital Association et al. v. Becerra, overturning Medicare rules that significantly reduced payments to 340B hospitals for outpatient drugs. The specific issue in the case was whether the Department of Health and Human Services had the authority under the Medicare Prescription Drug, …
In a very strongly worded letter, the American Hospital Association has urged the Department of Justice to establish a task force to conduct False Claims Act investigations into commercial Medicare Advantage insurers that routinely deny patient access to services and deny payments to health care providers. By law, Medicare Advantage plans are prohibited from imposing …
Mississippi Today has published its investigative report regarding Blue Cross and Blue Shield of Mississippi’s (BSBS-MS) “extraordinarily high” cash reserves and changes to its governance structure that have prevented those reserves from being used to reduce premiums or to pay providers more. The report found that BCBS-MS is holding $750 million in cash reserves, at …
Anthem’s first quarter 2022 earnings report showed that Anthem’s benefit expense ratio was 86.1%, lower than its expected ratio of 87.8%. An insurer’s benefit expense ratio represents the insurer’s spending on claims compared with its earnings from premiums. Anthem’s lower than expected benefit expense ratio means that it paid less to providers for medical costs …
On March 10, 2022, Highmark Health, a health services company affiliated with several Blue Cross Blue Shield companies, issued a statement revealing that a subcontractor of one of its mail vendors, Webb Mason Marketing, was involved in a data breach that may have impacted as many as 67,147 Highmark members. According to the notification letter: …
The Office of the Inspector General of the Department of Health and Human Services has issued a report entitled “Some Medicare Advantage Companies Leveraged Chart Reviews and Health Risk Assessments to Disproportionately Drive Payments.” The OIG undertook the review due to concerns that Medicare Advantage (MA) plans “may leverage both chart reviews and Health Risk …
The Department of Health and Humana Services Office of the Inspector General has issued a report estimating that the Medicare program made $2.6 billion in risk adjustment payments to Medicare Advantage organizations (“MAOS”) in 2017 based solely on diagnoses reported in Health Risk Assessments (“HRAs”). The OIG further found that 80% of the estimated payments …