Health Plan Weekly

Tucked into the 174-page Fiscal Year 2023 Budget in Brief document recently issued by HHS is a proposal seemingly aimed at giving the federal government more flexibility and power to sanction out-of-compliance Medicaid managed care plans.

“Currently, CMS has inadequate financial oversight and compliance tools in Medicaid managed care, lacking maximum flexibility to disallow and defer individual payments or partial payments associated with contracts with managed care organizations, prepaid inpatient health plans, and prepaid ambulatory health plans,” stated HHS in its budget proposal released on March 28.

Roughly a year after a highly critical report from an activist short seller cast a pall over Clover Health Investments Corp.’s debut as a publicly traded company, a federal judge has denied a motion to dismiss a key shareholder lawsuit that accuses the Medicare Advantage startup of hiding critical information from investors.

While the Feb. 28 ruling does not make any judgment about the merits of the allegations brought by shareholders Timothy Bond and Jean-Nicolas Tremblay, it is still noteworthy, one legal expert tells AIS Health, a division of MMIT.

“Often these cases are filed but then they’re disposed of early on,” says David Kaufman, an attorney with Laurus Law Group LLC. “This case was not disposed of, so getting beyond the motion to dismiss is pretty significant, and it’s going to require substantial litigation from this point forward before it reaches any kind of decision.”

Anthem, Inc. said recently that it will rename itself “Elevance” in a bid to be seen a diversified enterprise, known as much for its technology and business services branches as its traditional health insurance business. Anthem isn’t alone in its broad ambitions. The largest health insurance firms have all diversified their businesses, moves that are likely responses to the tight regulation and limited growth opportunities in health insurance for national-scale firms — and the encroachment of tech and investment firms into the health care sector.

The name Elevance, a combination of “elevate” and “advance,” isn’t official yet. Shareholders will vote on whether to adopt it during the firm’s May 18 investor meeting.

CalOptima, a Medi-Cal plan in Southern California, launched a five-year blueprint to cut through delays in care approvals and payments, as it seeks to deliver near-immediate claims processing and to put an end to prior authorization-related lags.

On March 21, CalOptima announced a $100 million investment in technology upgrades, which the Medicaid plan seeks to use to reduce barriers to care and to bridge divides — primarily centered on data-sharing — between the plan, providers and community partners.

The payer, which serves nearly 900,000 members in Orange County, also wants to get money into the hands of providers faster, with plans for an innovative “real-time claims processing” system.