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News
Medicare spent hundreds of millions of dollars on ineligible drugs, audit finds
6+ hour, 31+ min ago (558+ words) Shoddy CMS oversight is to blame, and the agency needs to do better, the HHS Office of the Inspector General said. Medicare Part D isn’t supposed to pay for drugs that can be purchased without a prescription. But the government’s…...
UnitedHealthcare cuts prior authorization from 1,700 codes
10+ hour, 32+ min ago (599+ words) The codes span a broad range of services across multiple specialties, including oncology and cardiology, orthopedic and musculoskeletal procedures and genetic and lab testing. Providers generally loathe prior authorization, a controversial process requiring them to get an insurer’s OK before…...
Monogram Health to pay $2.4M to settle Medicare Advantage upcoding allegations
1+ week, 14+ hour ago (303+ words) The DOJ told Healthcare Dive that Monogram, a home health company, overcharged Medicare through contracts with Cigna and Humana by inflating diagnostic codes. In Medicare Advantage, the CMS pays private insurers a fixed amount for each member every month, adjusted…...
Providence Health Plan to close completely after Medicare Advantage deal falls through
2+ week, 11+ hour ago (532+ words) The regional health plan was in talks with an unnamed national insurer to keep its MA plans afloat. But the agreement sputtered “despite significant effort on all sides,” per a spokesperson. Providence Health Plan covers about 440,000 people in a handful…...
Prior authorization denials vary widely among insurers, first-of-its-kind data shows
2+ week, 5+ day ago (367+ words) KFF analyzed new federal prior authorization data and found significant variation in how insurers handle requests across Medicare Advantage, Medicaid, and the ACA markets. The CMS issued a final rule in 2024 aimed at streamlining prior authorization processes for insurers. Although…...
Humana taps ex-Johns Hopkins exec as Medicaid leader
3+ week, 1+ day ago (350+ words) It’s part of a broader leadership transition announced late last year. Previous title: President and CEO of Johns Hopkins Health Plans New title: Senior vice president and president of Medicaid Holland is joining Humana effective Aug. 17 as the head of…...
Complete Health to pay $14M to settle Medicare Advantage fraud allegations
4+ week, 13+ hour ago (439+ words) The value-based primary care provider submitted false diagnosis codes to the CMS for three years, inflating its reimbursement by millions of dollars, according to the DOJ. In MA, the government pays insurers a fixed payment per member each month that’s…...
Medicare finalizes 2.3% hospital inpatient pay raise for 2027
4+ week, 2+ day ago (403+ words) Regulators also finalized the first nationwide, mandatory payment model to reduce the cost of joint replacements starting in 2028. Hospitals said the pay raise was inadequate. The Inpatient Prospective Payment System final rule includes a 3.2% market basket increase, offset by a…...
Out-of-Network claims are costing you more than you think
4+ week, 2+ day ago (1032+ words) Providers Are Winning 88% of IDR Disputes. Here’s what successful health plans are doing differently. The numbers are no longer surprising. They’re just expensive. For health plan CFOs and CEO’s, those figures represent real, trackable budget exposure, not a market-level abstraction....
CMS to end subsidies for Medicare drug plan premiums
1+ mon, 4+ day ago (356+ words) The program, which went into effect in 2025 to stabilize Part D premiums and enrollment, isn’t needed anymore, the agency said. The IRA, passed in 2022, included a number of changes to prescription prices and coverage, such as caps on out-of-pocket drug…...