The AMA and the Illinois State Medical Society are suing data analytics firm MultiPlan, alleging that it's at the center of a price-fixing conspiracy with health insurance companies that has hurt medical practices and, in turn, patients. The suit alleges that most of the nation's health insurance companies have outsourced to MultiPlan the task of deciding how much they should reimburse doctors and other providers who provide services to patients while out-of-network.
Allina Health has notified thousands of patients with Humana Medicare Advantage plans that their doctors might be out-of-network next year and therefore only available with higher out-of-pocket costs unless the Kentucky-based insurer agrees to a contract that reduces claims denials and prior authorization rules. The Minneapolis-based health system alerted about 18,000 patients of the potential disruption last week, just as Medicare open enrollment was getting underway.
Private Medicare insurers got about $4.2 billion in extra federal payments in 2023 for diagnoses from home visits the companies initiated, even though they led to no treatment, a new inspector general's report says. The extra payments were triggered by diagnoses documented based on the visits, including potentially inaccurate ones, for which patients received no other medical services, the report says. Insurers offering private plans under Medicare Advantage are paid more when patients have costly conditions.
Mercy, one of the largest health systems in St. Louis region and in the U.S., says it has teamed up with health insurance plan Centivo as its contract with Anthem Blue Cross is set to expire at the end of the year. Centivo will offer a health insurance plan to employers and employees in the city of St. Louis and St. Louis, Jefferson, Franklin and Lincoln counties, with coverage at Mercy facilities throughout Missouri with hopes to eventually expand across Mercy's four-state footprint.
PBMs have been systematically underpaying small pharmacies, helping to drive hundreds out of business. The pattern is benefiting the largest PBMs, whose parent companies run their own competing pharmacies. When local drugstores fold, the benefit managers often scoop up their customers, according to dozens of patients and pharmacists. The PBMs' power comes from two main sources. First, the three biggest players — CVS Caremark, Express Scripts and Optum Rx — collectively process roughly 80% of prescriptions in the United States. Second, they determine how much drugstores are reimbursed for medications.
Humana Inc., has filed a lawsuit against CMS in response to a recent cut in crucial Medicare quality ratings. The lawsuit is an attempt to reverse the decision which has already hurt its stock value and threatens a loss of billions of dollars in incoming revenue. The company claims that Medicare acted in an 'arbitrary and capricious' manner in calculating its metrics on the health plans offered by Humana. Star ratings play a crucial role in determining bonus payments worth billions of dollars. The latest downgrade spells bad news for the 2026 earnings targets that Humana has set, and one analyst called it a 'worst-case scenario' for the Louisville, Kentucky-based insurer.