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FTC Clamps Down on Allegedly Fraudulent Health Plans

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A federal judge temporarily closed a Florida-based firm accused of fraudulently collecting over $100 million from Americans. Simple Health allegedly collected more than $100 million by preying on consumers shopping for health insurance by...

HealthCare.gov Breach Exposes Data of 75K Individuals

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Last month, a breach of HealthCare.gov took place that affected those applying for coverage under the Affordable Care Act, HHS reported last Friday. The intrusion led to inappropriate access to the personal information of about 75,000...

Strategies for Designing Consumer-Centric Health Plans

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The Health Care Transformation Task Force recently released a new set of guiding principles to help healthcare industry leaders and policymakers better integrate consumer needs into benefit design. The goal of the task force, a consortium...

CMS Proposes to Deregulate, Fast Track Medicaid Managed Care Programs

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CMS has proposed a new rule to reduce regulation around Medicaid managed care programs and allow states to contract with private payers to deliver managed care at faster rates. CMS developed the rule in coordination with the National...

CMS to Audit Premium Subsidy Eligibility for Individual Health Plans

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CMS has proposed a new rule that would audit premium subsidy eligibility for individual health plan beneficiaries and monitor premium assistance programs through the federal insurance exchanges. The Patient Protection and Affordable Care...

US District Court Denies Appeal to Resolve Risk Corridor Payments

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Federal judges for the US Federal District Court of Appeals denied a request to reopen a case that could provide over $12 billion in risk corridor payments to payers. Moda Health Plan, BlueCross BlueShield of North Carolina, and Land of...

Employer-Sponsored Medicare Advantage Enrollment Up 12% for 2019

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Employer-sponsored Medicare Advantage (MA) enrollment for plan year 2019 increased by 12 percent, representing a bump of more than 443,000 individual members, according to a new analysis by Mark Farrah Associates. Individual Medicare...

Poor Data Quality in CA Medicaid Drives $4B in Improper Payments

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California's Medicaid program, Medi-Cal, made over $4 billion in improper payments to cover benefits for ineligible beneficiaries because of poor data quality and insufficient oversight, according to a new report from state...

Commercial, Managed Care Insurance Sectors Profits Boom in Q3

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Commercial and managed care payers experienced significant third quarter profits, reductions in healthcare spending, and enrollment growth, according to the latest financial statements from insurance companies. Medicare Advantage (MA),...

Retail Clinics, Surprise Bills Changing Healthcare Purchasing Patterns

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Consumers are changing the way they spend their healthcare dollars as the stress of surprise medical bills, coupled with new retail-style options, change the care delivery landscape. Two new consumer surveys reveal that changing...

BCBSAZ Shared Savings Program Reduces Hospital Readmissions by 26%

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BlueCross BlueShield of Arizona’s (BCBSAZ) shared savings program has reduced 30-day hospital readmission rates by 26.3 percent while generating shared savings for providers.. BCBSAZ also reported 15.2 percent fewer ED visits per...

CMS Redesigns Medicare Home Health Payment with Case Mix Model

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CMS has proposed a new rule that would recalculate Medicare home health payments using a case mix payment model.   In 2020, the agency plans to implement the Patient-Driven Groupings Model (PDGM) to compensate home health agencies...

Consumer Demand for High-Deductible Health Plans Dwindles

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Consumer demand for high-deductible health plans (HDHPs) is expected to decline in 2019 as more beneficiaries look for health plans with customized benefits instead, according to a new survey from Oliver Wyman. Half of consumers surveyed...

CMS Extends Medicare Advantage Audit Program in 2019 Rule

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CMS will be continuing its Medicare Advantage audit program, the agency indicated in a proposed 2019 rule, in an effort to ensure program integrity and reduce inappropriate payments to insurers. The changes are part of CMS’s new...

Can Payers Reduce Stress of Alternative Payment Models for Physicians?

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Alternative payment models (APMs) may be placing significant burdens and stress on physicians, requiring payers to make additional efforts to improve their communication and smooth the process of transitioning to value-based care,...

Cigna: Integrated Pharmacy, Medical Benefits Improve Overall Health

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Integrating pharmacy benefits with medical benefits can help to improve overall health and reduce employer costs, according to a new study released by Cigna. Individuals with connected medical, behavioral and pharmacy health benefits...

60% of Employers Fail to Address Healthcare Spending Waste

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Sixty percent of employers don’t capitalize on opportunities to address healthcare spending waste, even though they say wasteful spending is a key concern, according to a new survey from the National Alliance of Healthcare Purchaser...

CMS Grants NC 1115 Medicaid Waiver to Implement Managed Care System

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North Carolina has received a 1115 waiver from CMS allowing the state to implement a Medicaid managed care system administered through private payers. The state’s Department of Health and Human Services (DHHS) can now recruit...

New Drug Pricing Model Could Save Medicare Part B $17.2 Billion

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A new drug pricing model with an international component could save Medicare Part B approximately $17.2 billion over five years, CMS says.   The International Pricing Index (IPI) will test if using drug price benchmarks other...

PBMs, Specialized Formularies Reduce Managed Care Prescription Costs

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Pharmacy benefit managers (PBMs) with specialized drug formularies can help managed care payers significantly reduce prescription drug costs, according to new research published in the Journal of Managed Care and Speciality Pharmacy. The...

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