Ryan Ellison’s Post

According to a recent NYT article, insurers reap hidden benefits from MultiPlan’s incentives while under-reimbursing out-of-network providers. Community Health Systems filed a lawsuit against #MultiPlan, after the news of the company conspiring with health insurers to underpay providers. This lawsuit is the third of its kind against MultiPlan within a year - and more are on the horizon. This lawsuit alleges collusion on MultiPlan's use of repricing algorithms to calculate reimbursement amounts significantly below what insurers would typically pay. CHS claims this practice has cost them hundreds of millions of dollars annually, with billions lost across health systems. Learn more about this lawsuit: https://lnkd.in/eCG4iDdq

Three major hospital networks have now filed lawsuit against MultiPlan raising serious concerns about alleged anticompetitive practices that could have far-reaching negative implications within the healthcare industry itself. ## Systematic Underpayment to Providers The core allegation is that MultiPlan conspired with major health insurers to systematically underpay providers for out-of-network medical claims through opaque pricing methods. Litigants claim this scheme has cost providers at least $19 billion per year in lost reimbursements. ## Stifled Competition and Innovation Price-fixing agreements of this nature reduce competition and diminish incentives for companies to innovate, invest in new services, or increase efficiency. This could hinder progress and improvements in pricing models and healthcare delivery. Ultimately these impacts cost patients their health, quality of life, and sometimes worse. ## Potential Criminal Penalties If proven, price-fixing constitutes a felony offense that can result in heavy fines for companies and potential jail time for individuals involved. The allegations represent extremely serious legal and financial risks for MultiPlan. Overall, the lawsuits depict a purported conspiracy to depress reimbursements to providers through anticompetitive means, enriching insurers at the expense of the healthcare system's financial viability and ability to invest in advancing patient care.

(MODERN HEALTHCare) - "Health Rules 2024: What’s Next For Medicare, Prior Authorization." Pres. Joe Biden has some unfinished business on health policy, and the final months of his term in office will feature a flurry of regulations touching areas from Medicare payments to prior authorizations to cybersecurity. Find A More AFFORDABLE Health & DENTAL Insurance Plan At: HI4E.org #MedicareReform #MedicarePreCertification #MedicareAdvantagePlans #TrumpMedicareReforms #HealthRules2024 #HI4E.Org #GetAQuote #BidenMedicareReforms #MedicareAdvantagePlans #MedicareSolvency #MedicarePriorAuthorization #HealthInsurance4Everyone #SeniorCare #SeniorCitizens #MedicarePartA #MedicarePartB #MedicarePartD #RetirementPlans #NewToMedicare #HealthInsurance4Everyone #Retirees #HealthAndLifeSolutions #MedicareDentalPlans #MedicareDentalPlans

What is good for FFS #physicians and #hospitals is not necessarily good for #HealthInsurance providers. Every dollar of #HealthcareCosts is another person's dollar of healthcare revenue. All focus is on government payor contracts as #MedicareAdvantage enrollment hits 34 million, 80% of #Medicaid recipients (in 45 states) are now in #MedicaidManagedCare arrangements and #Obamacare exchange enrollment hits a record-breaking 22 million. And the percentage of the American population covered under tax-advantaged #employer-based coverage (most of which is self-funded, not an actual insurance product & easily the most lucrative part of healthcare for volume-based providers - hospitals are paid 260% of #Medicare on average) continues its long inexorable slide. #HealthcareReform #HealthcareTransformation #PublicPrivatePartnership #PublicPrivatePartnerships #HealthEquity #PrimaryCare #DSNP #HealthcareCosts #HealthcareQuality #BehavioralHealth #MentalHealth #TripleAim #PopulationHealth

I’m no fan of health insurers, but to simply demonize them and ignore the regulated environment in which they operate is a forest/trees fallacy. Two laws govern the vast majority of health plans onto which Americans enroll: ERISA (for self-funded employer plans) and Medicare Part C (for Medicare Advantage enrollees). My core concern with how these laws are currently structured is that they insulate both the federal government and employers from accountability; they obfuscate in a way that leads Americans to blame solely the insurer rather than focus at least some of their ire on the actors over which the beneficiaries may actually have more sway: their company and their government. This occurs in two ways: 1) both laws allow too much distance between the responsible party and core claims decisions: they force sick people to run a Rube-Goldberg-like appeals process that’s first few steps almost always involve the financially self-interested insurers. Moreover, they require patients to exhaust these “administrative appeals” before they can seek equitable relief in the federal courts. This creates scenarios where injustice can go unreviewed by a truly neutral arbiter: a federal district court judge and jury. ERISA goes even further and forecloses trial by jury even after you reach the federal courts! And it should go without saying that the expense involved in reaching this level of review is beyond what most Americans can afford. 2) both laws, but especially Medicare Part C, devolve too much responsibility for the initial claim determination to the insurer. The Medicare Act requires that beneficiaries receive medical care for treatments that are “reasonable and necessary”. This intentionally vague language is common in federal statutes. But what it means is that the implementing agency (CMS) must flesh this definition out. How is this done? By issuing National Coverage Determinations (NCDs). These bind insurers. But there are vanishingly few NCDs. Now Medicare Administrative Contractors (e.g. private insurers paid to administer Medicare A/B claims) can also issue what are called Local Coverage Determinations (LCDs), but again, while also binding, these focus on only a small minority of clinical scenarios. Moreover, the MACs are often subsidiaries of the same private insurers that offer MA plans (that's a topic for another rant on COI). So in practice, for seniors covered by MA plans, it is the financially self-interested health insurer that gets to determine, with surprisingly little substantive guidance, what’s “reasonable and necessary”. This devolution of responsibility is a FEATURE of the MA schema, not a bug. The thought is that insurers will be better equipped to evaluate medical evidence and appropriately expend Medicare dollars, perhaps saving the system money. This, of course, hasn’t panned out. MA ends up costing more. #healthcare #healthinsurance (continued in next post)

Is Big Health Care too big? The U.S. government is now investigating that question: The DoJ has launched an antitrust investigation into UnitedHealth Group, the largest U.S. health care company, according to the The Wall Street Journal and the Examiner News. Last year, Erika Fry and I looked into that very question for a Fortune cover story about the tremendous—and accelerating—growth of United and CVS Health, the country’s second-largest health care company. As we reported in May: Health care executives, investors, and some practitioners argue that this “vertical integration”—marrying primary care clinics and physicians’ practices to insurance, pharmacy benefit management, data analytics, and a host of related businesses—is, or will be, good for everyone. Companies can deliver care more efficiently and conveniently, providing more services to lower-income patients and other underserved populations, and heading off the chronic conditions and serious illnesses that drive up costs. …But the broader benefits are, so far, a matter of debate—and the focus of much skepticism among doctors, patients, lawmakers, and industry critics. “Everything about the incentive structure that exists, when you have providers and insurers and pharmacy benefit managers coming together under one roof, to me spells ‘conflict of interest,’ ” says Sara Sirota, a policy analyst at the American Economic Liberties Project, a nonprofit focused on antitrust advocacy. “That’s going to harm services and prices for patients.” The health care giants point to early signs of improvement, and promise even bigger benefits further down the road. In the meantime, they keep growing at a blistering pace. Which means it’s more urgent than ever to ask: Who benefits from Big Health Care’s growth—and will it really make America healthier? https://lnkd.in/eJvkytCM https://lnkd.in/e8m3KzBi

This behavior is our "healthcare" system in a nutshell. Who holds the cards??? Whoever pays you... The momentum of providers getting away from insurance relationships is only going to accelerate because of this. "But the massive insurer has been thus far reluctant to share its wealth with the desperate health care providers that can’t bill it, rolling out an emergency zero-interest lending program that has offered health care providers loans as small as $10 to “tide them over.” " This isn't every payer.... But it demonstrates the power dynamic in our system PERFECTLY. Want to rehab your image after something like this UnitedHealth Group? Maybe don't prey on the healthcare providers you just screwed over!!! #healthcare #insurance #system #business #hr #benefits

https://lnkd.in/eG47a2H3 The Canadian Medical Association (CMA) is proposing to restrict patients’ access to private virtual care services at a time when an estimated 6.5 million Canadians — per a recent OurCare study that was recognized by the CMA’s own medical journal — cannot access a family doctor. Additionally, millions more who have a family doctor wait days, if not weeks, to see their physician when they are in need. In fact, only 35 per cent of OurCare respondents could access same- or next-day appointments with their family doctor. The position being taken by the CMA is in direct conflict with the wishes of many CMA members, and with the public, at large. Use of the services continues to grow in popularity. The cost is primarily borne by employers and insurance companies, and the services offered help to alleviate some of the strain on an already buckling health care system.  #virtualhealth #healthcare #CMA #healthbenefits #benefitsspecialist #cgib #iscebs

Employers are increasingly seeking cost data from insurance payers to better understand and manage healthcare expenses, but their requests are often met with silence. This growing demand for transparency is underscored by the Consolidated Appropriations Act, which mandates that health plans disclose information regarding the cost and quality of medical services. However, the lack of responsiveness from payers has led employers to escalate the issue by resorting to federal investigations and lawsuits. This approach is taken as a last resort to address their dissatisfaction with the opacity surrounding payer-provided data, signaling a significant conflict in the pursuit of healthcare cost transparency and accountability.