Health Plan Weekly

In what whistleblower attorneys say is a novel case, Humana Inc. has agreed to pay $90 million to settle False Claims Act allegations related to the Medicare Part D contracting process. The case was brought by a former employee who alleged Humana engaged in a “reverse-engineering” scheme to submit actuarially equivalent bids to CMS for Prescription Drug Plan (PDP) business that were based on inflated assumptions about the use of preferred pharmacies by low-income subsidy (LIS) members. Humana did not admit wrongdoing and stands by the merit of its assumptions. 

The suit, U.S. ex rel. Steven Scott v. Humana Inc. (3:18-CV-00061-GNS-CHL), was originally filed in January 2016 in the U.S. District Court for the Central District of California. It remained under seal until 2017, after the U.S. Dept. of Justice (DOJ) declined to intervene.  

With tens of millions of enrollees now dropped from the Medicaid rolls, a group of 189 health care organizations have taken another step they hope will add permanency to the program. The coalition, organized by the Association for Community Affiliated Plans (ACAP) and Families USA, sent a letter on Aug. 13 to congressional leaders calling for 12-month continuous enrollment for adults enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). 

They asked for support of the Stabilize Medicaid and CHIP Coverage Act, which was introduced in the House by Rep. Debbie Dingell (D-Mich.) in September 2023 and in the Senate by Sen. Sherrod Brown (D-Ohio) the next month.   

The cost of providing health benefits to employees grew more than was projected in 2023 and is expected to rise by an eye-popping rate of 7.8% by 2025, according to an annual survey of large companies from the Business Group on Health. And to address those rising costs, employers are demanding greater accountability from their health plans, PBMs and other vendors. 

“Health care costs is really the headline story of this year’s findings,” Ellen Kelsay, Business Group on Health president and CEO, said during an Aug. 20 virtual press briefing. Health care trend — or the rise in spending — was 6.8% in 2023, which was up from 4.6% in 2022 and greater than the 5.9% estimated trend. 

With both the Republican and Democratic conventions now finished and a little over two months until the U.S. presidential election, speculation over how nominees Kamala Harris or Donald Trump would influence health policy is beginning to heat up. To that end, Harris’ recent release of her economic policy outline has offered more clues about her highest priorities — while one former Trump administration official says he expects Republicans to largely avoid health care issues during the campaign. 

“Just to be very clear, I think on the Republican side, you’re still not going to see much emphasis on health care,” Alex Azar, who was secretary of HHS under Trump, said during an Aug. 14 webinar hosted by Avalere Health. “President Trump is known to not just read from a teleprompter, so who knows,” he added, but it’s more likely that issues like inflation and immigration will be in the spotlight. 

In 2023, the federal government received more than three times as many surprise billing payment disputes it received in 2022, and provider groups continued to win the vast majority of cases while reaping higher payment amounts, according to new CMS data.

The No Surprises Act (NSA), passed in 2021, banned the practice of billing patients for the difference between what their insurer pays and what a provider charges when patients unknowingly receive care from an out-of-network provider. The law also established a Federal Independent Dispute Resolution (IDR) process that out-of-network providers and insurers can use to determine the OON rate that providers should receive if the two parties fail in their own attempts to negotiate.