The American Medical Association (AMA) and the American Hospital Association (AHA), the largest provider trade groups in the country, sued the Biden administration over regulations HHS issued in implementing the No Surprises Act. In a lawsuit filed Dec. 9 in the U.S. District Court for the District of Columbia, the AMA and AHA request injunctive relief of the latest interim final rule implementing the No Surprises Act. The Biden administration’s most recent rule aimed at implementing the surprise billing ban, which comes into effect on Jan. 1, 2022, has come under fire from provider groups — and members of Congress, many of them physicians — for “plac[ing] a heavy thumb on the scale of an independent dispute-resolution process that would unfairly benefit insurance companies,” in the words of an AMA press release.
So far during the 2022 open enrollment period for Affordable Care Act marketplace plans, approximately 3 million people have selected plans on HealthCare.gov. That running total includes 560,000 who selected plans during week four of open enrollment, according to CMS’s weekly enrollment snapshot.
Cigna Corp.’s Express Scripts is offering its health plan and employer clients a “first-of-its-kind” option to cover over-the-counter COVID-19 tests. Starting Jan. 1, 2022, members of participating plans will be able to choose an applicable COVID-19 test kit at a participating in-network pharmacy and show their Express Scripts member ID card at checkout to process the kit through their pharmacy benefit. Plans that opt into the new solution can set a copay for the COVID tests either at a discounted rate or $0. “Our new COVID-19 test kit solution creates more affordable and easily accessible testing options, ultimately contributing to safer communities and less disruption in our daily lives,” said Amy Bricker, president of Express Scripts.
CVS Health Corp. on Nov. 18 unveiled executive moves, as well as new store formats designed to “drive higher engagement with customers.” The firm, which owns health insurer Aetna, will also close approximately 300 stores per year for the next three years. On the executive front, Prem Shah will fill the newly created role of chief pharmacy officer, and he and Michelle Peluso will become co-presidents of CVS Health’s retail business. Neela Montgomery, current executive vice president and president of CVS Retail/Pharmacy, will leave the company at the close of 2021. Meanwhile, CVS’s new store formats will include sites dedicated to offering primary care services and an enhanced version of HealthHUB locations, alongside traditional CVS Pharmacy locations, the company said.
Oncopeptides AB is voluntarily withdrawing Pepaxto (melphalan flufenamide) from the U.S. market, the company disclosed on Oct. 22. The FDA gave the therapy accelerated approval on Feb. 26, 2021, in combination with dexamethasone for the treatment of adults with relapsed or refractory multiple myeloma who have received at least four lines of therapy and whose disease is refractory to at least one proteasome inhibitor, one immunomodulatory agent and one CD38-directed monoclonal antibody. The company said that the decision follows the Phase III OCEAN study, which “the FDA does not consider…meets the criteria of a confirmatory study.”
✦ Politan Capital Management LP, a new hedge fund led by longtime activist investor Quentin Koffey, plans to use its $900 million stake in Centene Corp. to replace several of the carrier’s board members, the Wall Street Journal reported on Nov. 3. Politan hopes to increase margins at the insurer, which have been lower than those at other large carriers. According to the Journal, Politan wants to put former WellCare CEO Kenneth Burdick and former Anthem, Inc. Chief Financial Officer Wayne DeVeydt on Centene’s board.
✦ CMS on Nov. 2 finalized changes intended to boost participation in the Medicare Diabetes Prevention Program (MDPP) expanded model. In the Calendar Year 2022 Physician Fee Schedule final rule, CMS finalized proposals to waive the Medicare enrollment fee for MDPP suppliers beyond the end of the public health emergency, shorten the program services period to one year by eliminating the second year of maintenance sessions, and redistribute all of the Ongoing Maintenance sessions phase performance payments to certain Core and Core Maintenance Session performance payments.
✦ During Centene Corp.’s Oct. 26 conference call to discuss third-quarter 2021 financial results, executives said the insurer will issue a request for proposals (RFP) in 2022 for PBM services. The move — which comes as Centene has been settling a spate of lawsuits filed by states over its PBM practices — is “going to be a huge opportunity for an external PBM,” Chief Financial Officer Drew Asher said during the company’s call with analysts.
✦ UnitedHealth Group will reprocess all of its commercial claims for COVID-19 vaccine administration after a federal investigation found the integrated health care giant paid providers less than 40% of the Medicare reimbursement rate for administering inoculations. Sen. Bob Casey, Jr. (D-Pa.), chair of the special committee on aging, wrote in a letter to UnitedHealth that it must inform the committee of the number of claims it expects to reprocess by Nov. 5. UnitedHealth will owe about $15 million for every 1 million claims it reprocesses, according to press reports.
✦ CMS has given itself another year to finalize a proposal to begin using an extrapolation methodology in recovering overpayments from Medicare Advantage organizations. The Trump administration in a November 2018 proposed rule (83 Fed. Reg. 54982, Nov. 1, 2018) said it planned to extrapolate the results of Risk Adjustment Data Validation Audits, starting with 2011 contract-level audits, and not apply a “fee-for-service adjuster” to account for inaccurate diagnosis codes in FFS Medicare data used to calibrate the MA risk adjustment model.