Radar on Medicare Advantage
-
News Briefs: Anthem Must Face Lawsuit Involving Alleged Failure to Delete Inaccurate MA Diagnosis Codes
A New York District Court judge denied Anthem, Inc.’s request to transfer a False Claims Act lawsuit to another district and to strike allegations contained in an amended complaint. The suit in question was filed by the U.S. Attorney for the Southern District of New York in 2020 and alleges that while conducting chart reviews aimed at identifying additional diagnosis codes for obtaining risk adjusted payment through the Medicare Advantage program from 2014 to 2018, Anthem neglected “its duty to delete thousands of inaccurate diagnoses” and “often generated $100 million or more a year in additional revenue” as a result. According to an opinion filed by U.S. District Judge Andrew Carter on Sept. 30, the company now known as Elevance Health filed a motion to transfer this action to the Southern District of Ohio (or dismiss the suit altogether) and to strike portions of the complaint referencing the government’s settlements with other MA organizations or health care providers
-
RFI Commenters Envision More Plan Flexibility, Improved Transparency in MA
After giving stakeholders a month to formulate their thoughts on how best to address a variety of aspects of the Medicare Advantage program, CMS received nearly 4,000 comments on its request for information (RFI). An AIS Health review of select letters reveals comments on a multitude of hot-button topics including beneficiary decision-making, marketing practices and plan oversight, and MA reimbursement.
CMS published the MA-focused RFI on Aug. 1 and asked for input by Aug. 31. The sprawling request asked commenters to consider dozens of questions on key topics such as health equity, risk adjustment, social determinants of health (SDOH), supplemental benefits and value-based care.
-
APG’s Susan Dentzer Discusses Value-Based Care Goals, Challenges Across Medicare
CMS’s Center for Medicare and Medicaid Innovation last year declared a goal of having all traditional Medicare enrollees in an accountable care arrangement by 2030. America’s Physician Groups (APG), which represents more than 300 physician groups that accept various degrees of risk with all payer types, including Medicare Advantage plans, wants CMS to apply that same goal to MA. In a recent comment letter on CMS’s request for information on the MA program, APG President and CEO Susan Dentzer urged the administration to incentivize the delegation of full risk to providers in MA.
-
Health Systems May See More Savings With Medicare Advantage vs. Medicare ACOs
A new study published in JAMA Network Open raises questions about whether health systems can actually achieve significant savings through the Medicare Shared Savings Program (MSSP), or if Medicare Advantage could be a better bet. To identify spending patterns in MA and MSSP’s Accountable Care Organizations (ACOs), researchers studied the characteristics and claims data of about 16,000 Medicare patients at Ochsner Health System (OHS), a large, academic system in Louisiana, from 2014 to 2018. Ochsner joined MSSP in 2013, and its ACO hosts more than 2,200 providers. It also offers Medicare Advantage plans via a partnership with Humana Inc.
-
In ‘Early Innings’ of Major Retail Collabs, UnitedHealth-Walmart Make Medicare Play
With a focus on Medicare Advantage beneficiaries, UnitedHealth Group and Walmart Inc. have struck a 10-year “wide-ranging collaboration” with value-based care elements that could ultimately extend into Medicaid and commercial plans. In addition to launching a co-branded MA plan, the partnership will connect Walmart Health clinicians with Optum’s analytics and decision support tools for value-based care delivery, and it represents the latest example of a major retailer seeking out a partner to grow its health care business.
Walmart already has a Medicare Part D partnership with Humana Inc. and in October 2020 launched a co-branded MA offering with Clover Health. The Bentonville, Ark.-based retail giant at the time also launched an insurance brokerage called Walmart Insurance Services. According to walmartinsurance.com, it sells plans from Anthem (Elevance Health), Arkansas Blue Cross Blue Shield, Humana, UnitedHealthcare and Centene Corp.’s WellCare. The site does not, however, list Clover Health, and a spokesperson for Walmart confirms that the collaboration ended in 2021.
The Latest
Complimentary Publications
Premium Categories
Premium Categories
Meet Our Reporters
Meet Our Reporters