Beth Loomis

📢 CMS Updates for LTC Facilities: Medicare Notices 📢 Stay compliant with the latest CMS updates on FTag 582! Key changes to the Notice of Medicare Non-Coverage (NOMNC) and Detailed Explanation of Non-Coverage (DENC) take effect on January 1, 2025. ✅ Educate staff on issuing NOMNC & SNF ABN ✅ Audit recent service terminations ✅ Review policies for compliance Check out our latest article to learn more! #LTC #MedicareCompliance #CMSUpdates

5

ICYMI: Our annual Transparency in Coverage report has been released. This report outlines data on claims, denials, and appeals for health insurers doing business in Pennsylvania. We examine this type of data to minimize patient health service and treatment denials and identify and alleviate any issues in this process. Read more at https://lnkd.in/eWDkZWbk.

7

𝐁𝐨𝐨𝐬𝐭𝐢𝐧𝐠 𝐓𝐫𝐚𝐧𝐬𝐩𝐚𝐫𝐞𝐧𝐜𝐲 𝐢𝐧 𝐏𝐫𝐞𝐬𝐜𝐫𝐢𝐩𝐭𝐢𝐨𝐧 𝐃𝐫𝐮𝐠 𝐑𝐞𝐛𝐚𝐭𝐞𝐬 The New Hampshire Insurance Department (NHID) is advancing transparency in prescription drug rebates through new reporting requirements for insurers and Pharmacy Benefit Managers (PBMs). Starting March 1, 2025, PBMs and insurers must submit detailed rebate data from pharmaceutical manufacturers, enabling NHID to track savings and their impact on policyholder costs. Similarly, the National Association of Health Data Organizations (NAHDO) implemented the NCP Data Layout, which includes a section on the Pharmacy Rebate (PR) File. This tool captures key rebate details—such as the National Drug Code (NDC), manufacturer, and total rebate amounts—standardizing data for clearer analysis of healthcare spending and drug affordability. Together, these efforts support accountability and fairer pricing for residents. For more information, check out the NHID website: https://lnkd.in/e_3kf_bf Learn more about the NCP Data Layout: https://lnkd.in/erdTcTPZ

14

In the battle against healthcare fraud, waste, and abuse, experts shed light on the underlying challenges. A recent Codoxo survey spotlights critical obstacles such as identifying providers of interest, which constitutes half of the SIU team’s focus, while operational issues surpass technological barriers. With departments grappling with these complexities, Codoxo's powerful Fraud Scope platform is proving indispensable in enhancing detection and improving ROI - as real-time survey responses from customers indicate. View our recent infographic to learn how AI is shaping the future of healthcare cost containment.  #fwa #paymentintegrity #aiinhealthcare 

14

With medical costs rising, #MedicaidMCOs can't afford to let audit programs under-perform. And that's exactly the direction Kern Health Systems' high-dollar claims review vendor was going: Only a few audits per year – and even fewer collections. “It was really status quo,” said the Senior Claims Director. So they found a new #PaymentIntegrity partner with a technology-first solution. And they went from $0 in high-dollar overpayment identifications to $3M in the first 9 months. Could this model work for your #HealthPlan? Read the full story at https://hubs.ly/Q02X_2vJ0 #CaseStudy

10

  Earlier this year, Centers for Medicare & Medicaid Services provided guidance encouraging #PACE organizations to start submitting risk adjustment data using the Encounter Data System.   Will the transition impact program risk scores or reimbursement? Read our blog post to find out and get answers to other key questions.   👉 Learn more: https://lnkd.in/eQ4dTmCQ #RiskAdjustment #ValueBasedCare

3

The CMS has implemented anti-fraud measures for ACA enrollments, including requiring three-way calls for brokers not affiliated with existing plans and suspending 850 agents suspected of unauthorized switching. While complaints have dropped 30% since these changes, concerns remain about rogue agents exploiting system vulnerabilities. Critics, including agent groups, argue that the measures complicate enrollment and lack due process, advocating for two-factor authentication instead. Unauthorized switches have led to issues like higher deductibles and unexpected tax bills, creating political challenges for the Biden administration during a period of record ACA enrollment.

1

My latest substack on Centene Corporation and their recent earnings report came in with a huge top-line beat, surprising investors and sending the stock up nearly 19% before settling at a 5% gain. As the leading U.S. provider in Medicaid and ACA/Marketplace, Centene continues to navigate complexities in government lines of business, with strong data to back up their performance. Here’s a snapshot of the results and what it means for their path forward: 💼 Revenue & Earnings: • Adjusted EPS of $1.62 and reaffirmed 2024 EPS guidance floor of $6.80. • Premium and service revenue climbed to $36.9 billion, a notable 10.5% YoY increase. • Centene executed $2.4 billion in share repurchases YTD, a strong commitment to capital deployment. 🩺 Medicaid: • Membership adjustments due to redeterminations reduced total Medicaid lives to ~13M. • Advanced discussions with states led to rate increases, helping address acuity misalignment. • Recently re-procured contracts in Pennsylvania, Iowa, and Michigan. 🏥 Medicare Advantage: • Significant STAR rating improvements with 46% of members now in 3.5+ star plans. • Realigned focus on dual-eligible populations and strategic investments in core regions. • Anticipated top-line revenue of $14-16B in Medicare Advantage. 💊 Part D/PDP: • PDP beneficiary growth to 6.8M as out-of-pocket caps shift reinsurance risk to payors under the IRA. • Introducing $1-$6.30 premiums for enhanced affordability. 🌐 ACA/Marketplace: • Over 4.5M ACA members, with 5%-7.5% margin expectations for 2025. • Anticipating mid-single-digit growth as open enrollment begins. 💡 AI & Data-Driven Initiatives: • Centene is leveraging AI for patient management and provider support to drive cost efficiencies. 📈 Health Benefits Ratio (HBR): • Elevated HBR at 89.2% for the quarter, with Medicaid at 93.1%, marking a high point as they stabilize. Conclusion: Centene has navigated challenges with agility, enhancing STAR ratings, growing PDP membership, and solidifying its ACA leadership. As we look to 2025, Medicaid stabilization, ACA competition, and reimbursement adjustments will shape their trajectory. The healthcare landscape is dynamic, but Centene’s proactive approach is positioning them for sustained growth. My substack with deeper details on the call and 10Q #healthcare https://lnkd.in/gBDBvDcK

18

2 Comments

🚨 Breaking News: Supreme Court Declines to Hear Challenge to $2.7B BCBS Settlement 🚨 The Supreme Court has opted not to hear a legal challenge to the nearly $2.7 billion Blue Cross Blue Shield Association (BCBSA) settlement. This decision follows an October ruling by a lower court that upheld the settlement, which resolves allegations that BCBS plans colluded by dividing geographic regions to avoid direct competition. The Blue Cross Blue Shield Association, which agreed to the settlement in 2020, expressed its approval of the Supreme Court’s decision, stating it looks forward to "the opportunity to begin to implement this settlement." Home Depot had challenged the Alabama district court's decision, arguing it could impede future antitrust actions against the Blues system. However, the Eleventh Circuit Court countered this argument, stating the settlement does not prevent the federal government or future class action suits from addressing antitrust concerns against BCBS plans. Additionally, the Supreme Court declined to hear a challenge regarding the legal fees in the case, which include a $667 million payout to attorneys, one of the highest-ever in a class action. This ruling marks a significant milestone in addressing and resolving longstanding antitrust issues within the healthcare sector. #SupremeCourt #BCBS #Antitrust #Settlement #Healthcare #LegalUpdate #ClassAction #BCBSA

1

1 Comment

Prior authorizations can be a very important tool as a check and balance to ensure that a patient is getting the most appropriate care at any particular time, but it can also be incredibly bureaucratic and burdensome for providers and patients. This adds administrative costs and potentially delays key treatments. There is no doubt the prior authorization process needs to evolve, and eliminating the process for primary care providers is a very logical step. Where do you believe the sweet spot is for maximizing the benefits of prior authorization while minimizing the added burden and costs?

5

📰 My latest Substack article, diving into Centene's impressive Q2 2024 earnings report. 📈 Despite challenging headwinds, Centene Corporation, under the leadership of Sarah London, has delivered one of its best quarters yet. Here are some key highlights: 💎 Revenue Growth: 5.2% increase through the first half of 2024 to over 80 billion. 💎 EPS Growth: 15% rise compared to Q2 2023, with EPS at $2.42, up from $2.10. 💎 Stock Performance: Almost 9% rally on Friday driven by strong EPS growth and a 34% surge in the ACA/Marketplace membership.. Sarah London's strategic shift away from vertical integration is proving to be a winning move, focusing on core strengths while divesting non-core assets. Here are some major takeaways from the earnings call: 🏥 Medicaid - Addressed acuity misalignment, Centene sees a brighter second half of 2024 as their PMPM rates will move upward. - Significant wins in Florida, Kansas, and Michigan. - Exciting LTSS launch in Arizona, with Oklahoma, Delaware, and North Carolina in launch mode. 👨‍⚕️ ACA/Marketplace - The Ambetter brand is shining as Centene is the largest domestic ACA/Markeplace provider with membership growth of 34%. - Premium subsidies are driving this explosive growth, with total enrollment now at 4.4 million beneficiaries - Premiums revenue hit $8.5 billion in Q2, a 49% increase quarter-over-quarter. 👵 Medicare (Wellcare) - Rebuilding the brand with an eye on growth in 2025/2026. - Focus on the dual-eligible market as a potential growth area. - STAR ratings improvements with the CMS adjustment but must feel good about their meta data for CAHPS/HEDIS -Strong PDP business positioning post-IRA as they feel good about their 2025 bids 💰 Investments/Divestments - Continued share repurchases with $851 million in Q2. - Divesting in non-core businesses like Magellan Rx, PantherRx , Apixio, etc. are now paying off for the company This quarter truly showcased Centene's execution on their longer term strategy. Impressive cause when everyone zigged....They zagged. Full article below: #Healthcare #Medicaid #ACA #Marketplace #Medicare #Centene #Earnings

21

1 Comment

What’s the $12-25 billion #scam most people have never heard of? It’s called Risk Adjustment fraud and it drains #Medicare money that should be used to help elderly patients keep their health up and costs down. Instead, that money is flowing into the pockets of enormously profitable insurance companies that participate in the Medicare Advantage program. So far, #whistleblowers, including clients of Whistleblower Partners, have played a central role in exposing these schemes, helping the government to recover billions. But there are billions more still untouched. Learn more here.

20

1 Comment

Despite some states’ troubles involving Medicaid consumer-directed care programs — most notably, New York has been grappling with high-profile controversy of late — such programs provide a means of diversifying personal care providers’ revenue sources and offer a safeguard against staffing headwinds. Polsinelli #homecare #homehealth #medicaid https://lnkd.in/eNSD9b_R

1

In case you missed it, CMS rolled out significant updates this July that every health plan administrator should be aware of. From the evolving Medicare Prescription Payment Plan (M3P) to new guidance on Parts C & D Enrollee Grievances and Organization Determinations, staying compliant has never been more critical. Get a detailed breakdown of what these changes mean for your plan in our latest blog, featuring insights from Kelly Thao, our Sr. Compliance Analyst. Dive into the blog here ➡️ https://ow.ly/GfAk50TG8SG #MedicareCompliance #HealthcareCompliance #HealthPlans #MedicareUpdates #HealthAxis #CMS #ClaimsProcessing #ClaimsManagement #Medicare #MedicareAdvantage #Prescriptions #AppealsAndGrievances #Consulting #CAPS #Determinations #HealthIT #HealthcareTechnology

22

Recent projections from Jefferies indicate a significant shake-up for insurers: - Humana: Faces the largest hit, with an expected $2.5 billion reduction in EBITDA and a staggering $16.37 EPS drop, marking an 83% decline compared to 2025 projections. - UnitedHealthcare: Set to lose $1.6 billion in EBITDA, alongside a $1.39 EPS decline (4%). - CVS/Aetna: A relatively modest gain of $100 million in EBITDA and a $0.05 EPS bump (1%). - Elevance: A $100 million reduction in EBITDA with a $0.30 EPS decline (1%). - Centene: A positive outlier, expected to increase EBITDA by $100 million and boost EPS by $0.10 (1%).

7

1 Comment

UnitedHealthcare won a lawsuit requiring CMS to recalculate its 2025 MA star ratings after a federal judge ruled CMS violated the Administrative Procedure Act by misclassifying a test call. The recalculated ratings could lead to significant financial gains for UnitedHealthcare through quality bonus payments in 2026. The decision marks CMS’s third recent loss in star rating disputes, following cases with Elevance Health and SCAN Health Plan, highlighting broader industry dissatisfaction with CMS's evaluation processes.

12

3 Comments