Average premiums and benefits for Medicare's prescription drug program and private Medicare plans are projected to remain stable in 2025 with premiums slightly declining, CMS announced. The premiums are of interest to consumers enrolled in Medicare Advantage plans run by private insurers who are then paid by the government, and the health plans themselves, who set premiums and benefits based on the reimbursement rates. The government has been trying bring down MA prices to the level of original Medicare. Private health insurers had argued cutting their rates would limit what benefits they offer, but the government's projections show they remain stable.
In the latest slap at a pharmaceutical company by a local government, the city of Baltimore has filed a lawsuit accusing Biogen of striking an "unlawful" scheme with the largest pharmacy benefit managers to block generic competition of a best-selling multiple sclerosis treatment. The effort allegedly originated as Biogen planned to fend off generic companies that hoped to sell lower-cost alternatives to Tecfidera which, several years ago, had been a franchise product and generated nearly half of its revenue. With looming patent expirations, Biogen sought to market a "next generation" version called Vumerity and convince doctors to switch patients to the newer drug.
California Attorney General Rob Bonta on Tuesday announced a settlement with L.A.-based U.S. Healthworks, a nationwide chain of occupational and urgent care clinics. The $7.7 million settlement resolves allegations that USHW knowingly kept millions of dollars from the State of California in unclaimed property, in violation of the Unclaimed Property Law (UPL) and the California False Claims Act (CFCA). The unclaimed property in question included patient balances due to overpayment. As part of the settlement, USHW must hand over unclaimed property totaling $1.5 million to the State Controller's Office. At times, urgent care centers carry patient balances due to overpayment. This happens when an insurance payment is more than was anticipated after patients pay out-of-pocket costs. While the urgent care should issue a refund in these situations, sometimes refund checks mailed to patients are returned or are never cashed. In March 2022, Attorney General Bonta filed a complaint alleging that USHW possessed unclaimed property as early as 2001, and did not file mandated reports with the State of California until 2018 after being notified of the Attorney General's investigation.
Millions of Americans are trapped in a 'ghost network.' As some of those people have discovered, the providers listed in an insurer's network have either retired or died. Many other providers have stopped accepting insurance — often because the companies made it excessively difficult for them to do so. Some just aren't taking new patients. Insurers are often slow to remove them from directories, if they do so at all. It adds up to a bait and switch by insurance companies that leads customers to believe there are more options for care than actually exist.
North Carolina officials had been quietly laboring for months on an ambitious plan to tackle the state's mammoth medical debt problem when Gov. Roy Cooper stepped before cameras in July to announce the initiative. But as Cooper stood by the stairs of the executive mansion and called for "freeing people from medical debt," the future of his administration's work hung in the balance. Negotiations were fraying between the state and the powerful hospital industry over the plan to make hospitals relieve patient debt or lose billions of dollars of public funding tied to the state's Medicaid expansion. The federal government hadn't signed off on North Carolina's plan, putting funding at risk. And not a single hospital official stood with the governor that day. In exchange for federal money, hospitals would wipe out billions of dollars of patient debt and adopt new standards to shield patients from crippling bills. "It's a model that the rest of the country could adopt," said Jared Walker, founder of Dollar For, a national nonprofit that helps patients get financial aid from hospitals.
Chicago-based Oak Street Health has agreed to pay $60 million to settle allegations that it paid kickbacks to insurance agents in exchange for their help recruiting patients. DOJ alleged that from 2020 to 2022, Oak Street had a program under which third-party insurance agents contacted seniors to market Oak Street to them. Agents would then refer interested seniors to an Oak Street employee through a three-way phone call. Oak Street would then typically pay the agents $200 per beneficiary they referred. The government alleged that Oak Street submitted false claims to Medicare because of violations of the Anti-Kickback Statute. CVS Health, which acquired Oak Street in 2023, noted in a statement Thursday that in the settlement, "There was no admission of — and we expressly deny — any wrongdoing."