Reimbursement

Lab Tests Are Most Common Claim Denied by Medicare

Medicare Advantage coverage denials by Aetna, the health insurance division of CVS Health Corp., totaled $416 million between 2014 and 2019, according to a new report published in the journal Health Affairs by researchers from CVS, the University of Pennsylvania and Harvard University. During that period, 1.4% of services, which would have added up to 0.68% of total spending, were denied.

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In Blow to PBMs, CMS Floats Reform of Part D Price Concessions

As part of a sweeping new Medicare Advantage rule, CMS recently proposed a policy aimed at reforming a reimbursement system that local pharmacies have long claimed is straining them to the breaking point. PBMs, on the other hand, argue that the proposal could hamper value-based contracting in Part D and potentially increase Medicare spending.

At issue are arrangements in which Part D plan sponsors can recoup money from pharmacies for dispensed drugs if the pharmacies do not meet certain metrics. Generally speaking, these payments to plan sponsors are known as price concessions, and when assessed retrospectively — as they currently are — they are counted as direct and indirect renumeration (DIR).

CVS Health Will Spend Up to $25 Billion on Provider M&A

At the firm’s annual investor conference, CVS Health Corp. executives promoted closer vertical integration and promised to move even further into care provision. CVS, which acquired Aetna in 2018, emphasized virtual care and its retail HealthHUB clinics in recent months, and it has indicated it has a strong interest in acquiring providers, particularly in primary care.

Other large carriers have made similar moves in recent years. UnitedHealth Group owns both the U.S.’s largest health insurer, UnitedHealthcare, and a growing provider arm, OptumCare. Humana Inc. has moved to acquire in-home and primary care providers. Meanwhile, CVS’s largest retail pharmacy competitor, Walgreens Boots Alliance Inc., is purchasing clinics with the goal of becoming a major primary and urgent care provider. According to CVS Health CEO Karen Lynch, the firm’s position astride all three businesses — retail, care delivery and benefits management — is why it will perform better than its rivals.

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Ahead of 2023 Rate Setting, BMA Issues End-of-Year Wish List

As CMS gets ready to set Medicare Advantage rates for the 2023 calendar year, the Better Medicare Alliance in a Dec. 6 letter urged Administrator Chiquita Brooks-LaSure to take several actions to address social determinants of health (SDOH) and close the gap on longstanding racial disparities. The research and advocacy group supports more than 170 ally organizations that include several major MA insurers. Among its recommendations, BMA asked that CMS:

Insurers Balk at Idea of Covering Unlimited At-Home COVID Tests

Recently, the Biden administration unveiled a plan to curb COVID-19 infections that promises forthcoming guidance “to clarify that individuals who purchase OTC [over the counter] COVID-19 diagnostic tests will be able to seek reimbursement from their group health plan or health insurance issuer and have insurance cover the cost during the public health emergency.”

Health insurers and health care policy researchers have a bevy of questions and concerns about this plan — and at least one public health expert has floated a different approach.

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Report Trains Critical Eye on PBMs’ Changing Profit Streams

A new report about PBMs’ “evolving business models and revenue” is making a stir, with the main PBM trade group arguing that the organization behind it is biased and its conclusions are misguided. But industry observers tell AIS Health that the analysis offers illuminating information about how vertical integration and other factors have shaped the PBM sector — and they warn that PBMs must truly change if they are to survive increasing scrutiny.

TeamHealth Wins One Battle in Ongoing War With UnitedHealth

A jury recently found UnitedHealthcare underpayed Nevada emergency care subsidiaries of TeamHealth Inc. in out-of-network billing scenarios — and it’s the first of several ongoing suits between the two health care firms to wrap up. Experts say that the No Surprises Act, which comes into effect next month, will fix some of the issues raised in the lawsuit, but also point out that settling out-of-network billing disputes remains a matter of leverage.

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Biden: Health Insurers Should Pay for Home COVID Tests

In remarks to staffers at the National Institutes of Health (NIH) on the federal response to the omicron variant of COVID-19, President Joe Biden said his administration intends to make home testing more accessible — and require insurance companies to cover the cost of those tests from retailers.

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Obesity Management Targets Complex Disease via New Drugs, Better Awareness

Despite significant medical advances in the U.S. on numerous fronts, obesity management seems stalled by many clinicians’ reliance on a regimen of “diet and exercise” alone to treat as well as prevent. Obesity medicine specialists cite the increasing availability of safe and effective anti-obesity medications on the market — with dozens more in the pipeline — to allow for a multipronged treatment approach, but they point out that physicians seldom prescribe such drugs, and insurers often balk at paying for them.

This is partly because individuals with obesity, an increasingly prevalent, serious and costly disease, continue to confront the societal bias that “lifestyle choices” are to blame, experts say. It is also because obesity is a complex disease to treat, not merely a matter of gauging body mass index (BMI), they explain, and unless treated effectively, it may become the pathway to a wide array of chronic conditions including heart disease, stroke, type 2 diabetes, asthma and some types of cancer, as well as disability and premature death.

Recent MA Coding Complaints Signal DOJ’s ‘Evolving Expectations’

The risk adjustment system used to pay Medicare Advantage plans continues to face intensifying scrutiny from the federal government, with the Dept. of Justice (DOJ) intervening in multiple False Claims Act (FCA) complaints and the HHS Office of Inspector General focusing on retrospective chart reviews and high-risk diagnosis codes. Now, attorneys say health care providers should be on high alert as well. While prior DOJ complaints-in-intervention have focused largely on MAOs conducting “one-way” chart reviews, more recent lawsuits focus on the use of “addenda” — information retroactively added to a patient’s medical record — which one law firm says indicates a new area of scrutiny.