Medicare Advantage (MA) insurers, namely industry titans UnitedHealth Group and Humana, could be using health risk assessments and chart reviews to inflate payments from Medicare through upcoding, according to a federal watchdog report. An estimated $7.5 billion in risk-adjusted payments was pocketed by MA insurers when diagnoses were only found on chart...
Humana, one of the country’s largest Medicare Advantage organizations, is suing the Centers for Medicare & Medicaid Services over its 2025 star ratings results. In a lawsuit with nonprofit trade association Americans for Beneficiary Choice, the insurer said the federal government's “arbitrary” actions violates the Administrative Procedure Act. “The data and calculations underlying the annual...
In the past 12 months, 92% of healthcare organizations reported experiencing at least one cyberattack, up from 88% in 2023, an Oct. 8surveyfrom Proofpoint and Ponemon Institute found. Of those cyberattacks, 69% reported disruptions to patient care as a direct consequence.
The state of Texas is accusing major pharmacy benefit managers and drug companies of colluding to raise the cost of insulin. Texas alleged drug manufacturers Eli Lilly, Novo Nordisk and Sanofi raise the price of insulin and then pay an undisclosed amount back to PBMs Optum Rx, Express Scripts and CVS Caremark through a quid pro quo agreement. PBMs then give preferred status on its standard...
If a patient receives a continuous glucose monitor device through their medical benefit, they may be more adherent and may have lower costs, according to a new analysis. Researchers at CCS, which offers clinical services and home delivery for medical supplies for people with chronic conditions, published the peer-reviewed study this week in the Journal of Medical...
The Federal Trade Commission is suing the titans of the pharmacy benefit manager industry for anticompetitive practices and artificially raising the price of insulin drug prices, the agency announced Friday. The complaint alleges that Optum Rx, Express Scripts and Caremark—all vertically integrated with UnitedHealth Group, Cigna and CVS Health, respectively—caused patients to pay more for...
A new study suggests major pharmacy benefit managers may be focusing on specific payer segments in a bid to maintain strong market share. The analysis,releasedin the Journal of the American Medical Association, finds that CVS Health's Caremark holds the largest market share overall in the PBM space. However, it led by the largest margin Medicaid managed care, controlling 39.2% of the market.
CMS isnotifyingnearly a million Medicare beneficiaries of a data breach in which a hacker copied patients' files. The breach originated with Wisconsin Physicians Service Insurance Corp., an administrative services contractor for CMS that used the MOVEit file transfer software from Progress Software. MOVEit had asecurity vulnerabilityin 2023 that left its clients' data susceptible to...
The Department of Health and Human Services (HHS) is dropping its appeal of a June U.S. District Court ruling that vacated the government's restriction of third-party online tracking technologies on hospital webpages. The white flag came 10 days after the administration had filed its appeal to the Fifth Circuit. The casehad been brought in late 2023 by the American...
Hospitals across the U.S. are incorporating artificial intelligence into administrative and clinical workflows, testing the waters with one of the most disruptive forces in any industry today. C-suite leaders are gathering information and beginning to forge a plan for safely leveraging AI to its full potential, but the rapid pace of change means and increased costs of...
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