Gary Ashburn

Major Changes Coming For The KC Market 📢 Blue KC to Exit Medicare Advantage Market by 2025 Due to Regulatory Demands 📢 Blue Cross and Blue Shield of Kansas City (Blue KC) has announced its departure from the Medicare Advantage (MA) market by the end of 2024, citing increased regulatory demands and financial pressures as primary reasons for the decision. The company will shift its focus to employer-sponsored health plans, Medicare supplement plans, and Affordable Care Act plans while ensuring uninterrupted, quality service to current MA members through 2024. With a smaller MA membership base, Blue KC finds it challenging to compete economically at scale, leading to the difficult but necessary market exit. In a statement, Blue KC's President and CEO, Erin Stucky, expressed disappointment, saying, “We explored every alternative path for our MA members and are disappointed we must exit this line of business.” This move aligns with industry trends, as other insurers, like Oscar Health, have also exited the MA market due to similar challenges, including the impact of regulatory changes such as the CMS's benchmark payment adjustments on the profitability of MA plans for smaller insurers. #Healthcare #MedicareAdvantage #BlueKC #RegulatoryChallenges #InsuranceIndustry #HealthPlans #CMS #MarketExit

3

1 Comment

Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

5

1 Comment

As the use of artificial intelligence in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials should be scrutinized by providers to ensure the denial is appropriate. Read more at https://lnkd.in/e_yBqb4t

2

#CMS will require states and #Medicaid insurers to annually report how carriers spend state-directed payments to #providers, how their rates compare to #Medicare, and survey #ManagedCare enrollees about their experience with insurance companies. CMS also mandated states create “one-stop-shop” websites that allow enrollees to compare the quality ratings of #MedicaidManagedCare plans. Hmm. Medicaid continues to look more and more like #MedicareAdvantage with each new set of federal rules: more ongoing #HealthcareReform on the margins via national rule-making. #HealthcareTransformation #TripleAim #QuadrupleAim #PrimaryCare #SDOH #PopultionHealth #PublicPrivatePartnership #PublicPrivatePartnerships #DSNP #DualEligible #BehavioralHealth #MentalHealth #HealthEquity #FoodisMedicine #HealthcareQuality #HealthcareCosts #HHS

15

2 Comments

📉 Elevance Health 3Q Earnings Recap: What Went Wrong? On October 17, Elevance Health reported its Q3 earnings, and the market reaction was swift—a 15% drop. The major culprit? A soaring Medical Loss Ratio (MLR) of 89.5%, up by 270 basis points from Q3 2023. The primary driver: Medicaid reimbursement misalignment, which has burdened payors across the board. The mismanagement of Medicaid redeterminations led to a per-member cost spike, which wasn’t matched by state reimbursement increases, pushing Wall Street into a broad sell-off of the “Big Six Payors.” 📉 Despite these challenges, Elevance’s revenue still grew by 5%, reaching $44.7B. Their membership remains steady at 45.8 million, with ACA and commercial gains offsetting Medicaid losses. Key Takeaways from the Earnings Call and 10-Q: • Medicare Advantage: Conservative bids for open enrollment amid CMS rate cuts. While Elevance improved Medicare Star ratings on 60% of measures, one of their 4-star plans narrowly missed CMS’s cut-off, costing them. • Medicaid: CFO Mark Kaye noted cost-per-member increases as high as 3-5x in some states, driven by a shift to sicker populations post-redeterminations. With half of the state rate adjustments set for January, there’s hope that reimbursement alignment will improve. • Carelon’s Growth: Low 20% growth anticipated as Carelon expands its specialty drug offerings, with recent acquisitions of BioPlus, Paragon, and Kroger Specialty. Their latest acquisition of Carebridge further solidifies Carelon’s role in Elevance’s growth strategy. The specialty drug assets will be driving new value for larger employers they seem to attract. • AI Investments: Elevance is pursuing AI to streamline internal operations and enhance member experiences. This investment is set to mature through 2025, aiming to improve productivity and personalization. While Wall Street’s reaction may seem like an overreaction, the strategic groundwork Elevance has laid—especially in Carelon and specialty pharmacy—positions them for a potential rebound. Expect Carelon to become a key revenue driver as Elevance navigates the current Medicaid headwinds. For a deeper dive into the Elevance Health earnings for Q3 feel free to read and subscribe to my substack! #Healthcare

20

3 Comments

OIG ALERT: The first OIG report since February came out on Friday. Not shocking but the findings continue to be consistent with previous reports. If you need help assessing your risk, let me know. The report that came out Friday looked at 2016 and 2017 claims that Independent Health Association submitted to CMS for risk adjustment. The OIG focused on 8 target areas seen to have consistently high false positive rates. In this case they found that 230 of the 247 conditions reviewed, or 93%, did not have documentation to support the conditions submitted. The total takeback for this $646k for the two years. However, if the results were extrapolated, as can be done beginning in 2018, the takeback would have been 10X larger at $7M. The areas reviewed included: -Acute Stroke: 100% incorrectly captured -Acute Heart Attack: 97% incorrectly captured -Embolism: 90% incorrectly captured -Lung Cancer: 100% incorrectly captured -Breast Cancer: 100% incorrectly captured -Colon Cancer: 97% incorrectly captured -Prostate Cancer: 93% incorrectly captured -Miskeyed Diagnoses: 73% incorrectly captured For my followers by now this shouldn't be an earth shattering report. One of our 45 best practices for a strong risk adjustment program is to have stops in place to prevent these claims from going out the door without a review. Stay tuned for more updates and summary stats that aggregate the findings from these OIG reviews. https://lnkd.in/ec2R9C-G

103

13 Comments

Four Best Practices to Improve Risk Adjustment Compliance To thrive in the evolving risk adjustment regulatory environment, organizations must adopt proactive measures. While I have an entire list of how to ensure you are capturing conditions to depict complexity, here are four proven strategies to help drive risk score compliance: -Educate Providers: Offer regular training on documentation and coding. Make this a part of the norm, not an abnormality. A system in Arizona I partnered with brought education to providers in a one on one manner twice per year. They shared information about coding, performance, and use of technology. The investment paid dividends. -Pre-Bill Reviews: Evaluate high-risk diagnoses before claims submission. Additionally, through leveraging natural language processing technology (NLP) you can expand the volume of diagnoses reviewed to optimize reach. -Single-Time HCC Reviews: Audit conditions captured only once annually. (Note- I had another post on this one specifically so go scope it out) -Retrospective Reviews: Identify gaps and remove unsupported diagnoses. Retro reviews are a tremendous tool for MA and ACA populations. Not only should you be using those to capture missed conditions but this is the opportunity to correct for any over-capture. Success in risk adjustment isn’t just about capturing conditions—it’s about ensuring they’re defensible. The goal is a complete and accurate risk score. With audits increasing, these best practices aren’t optional; they’re essential. Which of these practices does your organization prioritize? Do you have any others you’d recommend, that you’ve found work better? I’d love to share ideas; let me know in the comments below.

63

13 Comments

🚨 Breaking News in Healthcare! 🚨 MultiPlan and major insurers, including UnitedHealth, Aetna, Kaiser Permanente, and Cigna, are facing a proposed class action lawsuit. The suit, filed by Live Well Chiropractic PLLC, alleges that these companies have colluded through MultiPlan's pricing tools to systematically underpay out-of-network providers. According to the complaint, MultiPlan's repricing algorithms suppress reimbursement rates, forming a cartel with insurers to fix prices and deprive healthcare providers of fair payments. This alleged scheme is said to have resulted in over $19 billion in annual underpayments, contributing to financial hardships for many providers. The antitrust lawsuit highlights growing concerns about software intermediaries influencing pricing decisions in the healthcare industry. The complaint includes claims for violations of sections 1 and 2 of the Sherman Act. MultiPlan denies these allegations, asserting their commitment to lowering out-of-network costs and reducing patient out-of-pocket expenses. Stay tuned for more updates on this developing story. #Healthcare #Antitrust #RevenueCycleManagement #MedicalBilling #MultiPlan #Insurance #HealthcareProviders Read the full article here: https://lnkd.in/e3-mKr7z

11

The Centers for Medicare & Medicaid Services (CMS) is recalculating MA quality ratings for 2024 following recent court rulings in favor of SCAN Health Plan and Elevance Health, who contested errors in these star rating methodologies. This industry-wide adjustment may increase bonus payments for insurers, requiring plans with improved ratings to resubmit their bids. Connect with our experts today to improve member satisfaction and take a step forward to boost your plan's star ratings. #CMS #Medicare #Medicaid #HealthPlans #QualityRatings #StarRatings #Healthcare #Insurance #CourtRulings #SCANHealthPlan #ElevanceHealth #BonusPayments #Insurers #MemberSatisfaction #HealthcareExperts #MedicareAdvantage #HealthcareIndustry #mhc #florida #usa #ImproveRatings #HealthCareReform #HealthInsurance

9

😳Humana faces a significant challenge following the release of preliminary 2025 Medicare Advantage (MA) Star Ratings data from CMS. Only 25% of its MA members are now enrolled in plans rated 4 stars or higher, a steep decline from 94% in 2024. 👉🏻The drop was driven primarily by the performance of contract H5216, which covers nearly half of Humana’s MA members, including over 90% of its Group MA plans, and saw its rating fall from 4.5 to 3.5 stars. 💴This will impact quality bonus payments in 2026. Humana is actively appealing some results and working to improve operating discipline to regain its industry-leading position. 🧘Key initiatives will focus on member engagement, customer experience, and technology enhancements to drive long-term value. Medicare Advantage open enrollment kicks off 10/15 and goes until 12/7. STAR ratings expected to be released to the public around 10/10! 📉Down 22% in premarket! https://lnkd.in/gUTT84tR

41

1 Comment

Medicare Advantage plans require an increased commitment to improving risk adjustment coding practices while optimizing medical record retrieval and interoperability. But health plans don’t have to handle these challenges alone! Watch our on-demand RISE webinar, where Cotiviti’s risk adjustment experts unravel trends shaping 2024 and beyond. https://bit.ly/49HsK7m #RiskAdjustment #HealthPlans

24

Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

6

Time for quarterly earnings season: - Elevance Health (Anthem) - reports increased revenue despite loss in membership due to the increased PBM revenue from CarelonRx. - CVS Health - "PBM profits continue to outperform driven by Cordavis contribution and Specialty growth" - Cigna Healthcare - Quarter over quarter PBM membership was down and yet - 2Q Express Scripts by Evernorth profit was up 7% driven by 3% growth in the PBM - UnitedHealth - "In the first half of the year, revenues grew by nearly $14 billion with strong contributions from across the enterprise, led by double-digit growth in Optum" Employers these companies thank you for your continued support in helping them drive record profits. Elevance Health is particularly excited and bullish on the opportunity ahead of them to force employers to use CarelonRx. I recently heard that they have an internal terminology used by the underwriting team when clients ask for pass-through PBM pricing. They call it "tinted glass" and have various models or levels they provide based on how smart the client is and how hard they are pushing. Dealing with these companies is like going to Vegas. The house always wins. While legacy PBMs continue to extract money from employers across the country SmithRx continues to focus on saving money for our clients. You dont have to trust us. You can ask our clients or look at our google reviews (since every other PBM hides those too). #pharmacybenefits #employeebenefits #PBM Rich Hejny Taylor Rogers

100

5 Comments

The California Office of Health Care Affordability has recently approved a requirement that all healthcare providers report their annual operating expenses. If those expenses increase more than 3.5% (eventually lowering to 3%) in a year, that provider will be fined, ironically increasing their expenses. The state claims this regulation is aimed at protecting consumers from high healthcare costs. This is the same State of California that recently raised all healthcare workers' minimum wage to $25 per hour (up from $15.50).  For our health system, that results in a $30 million annual cost increase and a 7.5% increase in our salary costs. This is also the same state that passed an unfunded mandate that requires our system to spend about $1 billion to replace a hospital building that they feel is at risk from damage in an earthquake. And it’s also the same state that increased the cap on medical malpractice lawsuits…and has authorized utility companies to raise their rates 15% per year.  So, with all of these unfunded requirements and policies that dramatically increase providers' costs beyond their control, how exactly does the state suggest that we limit our expense growth to 3% per year?  Healthcare cost inflation has already been running at more than 5% before any of these new requirements took effect. Perhaps if California wants to get serious about reducing the cost of healthcare they might look at the managed care plans. The most recent data I could find from the California Health Care Foundation indicates that California managed care companies made $222 billion in 2020. What direct value did these companies provide to the health of our communities? Meanwhile, hospitals and physicians are providing direct patient care and struggling to survive- especially systems like Kaweah Health that serve a high percentage of Medi-Cal (Medicaid) and Medicare patients.  On a side note, the governor did sign a new managed care organization tax into law this year, which was promised to increase Medi-Cal reimbursements to providers, but all signs suggest that he now intends to use those proceeds (nearly $7 billion) to fill holes in his budget's general fund deficit and will not be providing Medi-Cal rate increases. I would humbly suggest that if the state is genuinely concerned about its residents' cost of living, they might look at the state income tax (highest in the country), its gas prices (highest in the country), the essentially unaffordable housing costs, or countless other factors that will have a larger impact on individuals' pockets than beating up healthcare providers with laws that don't make any sense. #hospitals #california #healthcare

106

19 Comments

Interesting trends in the insurance industry

3

2 Comments

Value = Quality/Cost So to truly improve value, you can improve quality, reduce cost, or both. Many MA plans did neither. They just increased revenue by optimizing risk adjustment revenue, which is how you increase price in the risk adjustment model. Same quality at a higher price cannot lead to value. Medicare Advantage plans are licking their wounds, discontinuing plans, paying penalties for over-billing and exiting markets. Why? In large part because they were enamored with increased revenue from maximizing risk adjustment, but didn't have the foresight and discipline to couple the diagnosis capture with meaningful care improvement. The solution: If you document a diagnosis, do something clinically meaningful to improve quality of care in a way that prevents downstream costs due to hospitalization or unnecessary treatment. This is not the same as UM, which is based on denials and prior authorization, which are main tools used by most health plans. You just diagnosed COPD? First off, make sure your diagnosis is solid. Did you use a symptom assessment tool followed by spirometry? Once ACCURATELY diagnosed, refer to virtual pulmonary rehab and a high value care management program. Same for CHF, DM, severe asthma, ckd3+, afib, etc... Forget MEAT, which has been the risk adjustment documentation mantra (manage, evaluate, assess, treat). Instead, try DDD: Diagnose, then Do something Dummy...

1

1 Comment

Great Report by Kodiak. As we continue to navigate the complexities of healthcare payments, it's clear that we need to address the growing challenge of initial Request for Information (RFI) claim denials. These denials are becoming more frequent, and they’re costing both providers and payers more time and money than ever before. Since 2023, there has been a steady increase in these denials, which require providers to submit additional information before claims can even be reviewed. What does that mean in layman terms? RFI Claim Denial Rate: The rate of initial RFI claim denials rose from 3.51% in 2022 to 3.82% by May 2024. Administrative Costs: The cost of responding to these denials reached nearly $2 billion in the first five months of 2024, which, if extrapolated, could total around $4.6 billion for the year. Inpatient vs. Outpatient: Inpatient care is hit hardest, with denial rates climbing to 4.54% for inpatient services in early 2024, compared to 2.96% for outpatient. Key Offenders: Traditional Medicaid and commercial payors are the main drivers of these denials, with initial denial rates of 9.23% and 8.14%, respectively, for inpatient claims. | Metric                                | 2022| 2023 | 2024-May) | | RFI Claim Denial Rate       | 3.51%  | 3.68%| 3.82% | | Administrative Cost         | $1.5B    | $1.7B | $1.9B| | Inpatient Denial Rate        | 4.20%  | 4.33%| 4.54%| | Outpatient Denial Rate     | 2.69%  | 2.90%| 2.96%| | Medicaid Denial (IP)                                   | 9.23%| | Commercial Denial (IP)                                | 8.14%| These stats highlight the critical need for implementing advanced payment integrity software. By adopting next-generation tools that can accurately identify which claims need review, with probability of successful outcomes in advance (DRG, IBR's Coding) and why, we can significantly reduce the administrative burden and keep our focus on what truly matters—providing quality care without unnecessary delays. AMS (Advanced Medical Strategies)David Cardelle RPh John-Michael Loke https://lnkd.in/eBhVD3Fu

11

3 Comments