Health Plan Weekly

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.

When CMS on Aug. 15 revealed the prices of the 10 drugs subject to Medicare price negotiation, its much-anticipated disclosure still left many questions unanswered. In the managed care world, the biggest question mark remains how Medicare Part D plans will adjust their formularies in reaction to the new government-set prices — but one industry expert says it will be a while before more clarity emerges. 

“These prices are effective Jan. 1, 2026, so they should not, in theory, impact the 2025 formularies,” which have been largely decided since April, says Jennifer Snow, founder of the health policy and reimbursement consulting firm Apteka LLC.  

More than 30 states last year considered or introduced legislation to reform prior authorization, due in large part to lobbying from physician groups that indicate they are being subject to more PA requirements from insurers, according to a recent analysis from the Georgetown University Center on Health Insurance Reforms (CHIR). While health plans in recent months have touted their reduction in PA mandates, Sabrina Corlette, one of the report’s authors and CHIR’s co-founder, says providers and their staff still are spending numerous hours each week on PA and identify it as a major burden. 

Corlette and her colleagues primarily focused on four states — Arkansas, Illinois, Texas and Washington — that have enacted comprehensive PA reform in the commercial insurance market.  

So far, 2024 has proven to be an eventful year for publicly traded health insurers — and not always in a good way.  

Indeed, during the most recent quarter CVS Health Corp. made waves by adjusting its earnings outlook downward for the third time this year and dismissing the short-tenured president of its Aetna health benefits division due to ongoing Medicare cost pressures.  

Other publicly traded firms, including Humana Inc. and Elevance Health, Inc., offered better second-quarter performances, but still saw their share prices fall amid investors’ concerns about how medical costs will shake out in the second half.