Preview: Health Plan Weekly

Medicaid Fraud Suit Could Hurt Aetna’s Future Bid Chances

September 17, 2021

A recently unsealed whistleblower lawsuit accuses CVS Health Corp.’s Aetna of defrauding the Commonwealth of Pennsylvania and the federal Medicaid program by knowingly misrepresenting the number of pediatricians in Aetna’s Medicaid network. While the outcome of the suit is far from certain, and the Dept. of Justice opted not to intervene in the matter, legal experts say the case may have merit — and Medicaid insiders say that Aetna’s reputation may take a hit.

Carol Wessner, a nurse and former Early and Periodic Screening, Diagnostic and Treatment consultant for Aetna, alleges in a recently unsealed lawsuit that pediatric primary care was practically inaccessible to Aetna’s Medicaid members because of its incorrect provider directory. The insurer covered 265,868 Medicaid lives in 2020 under the Aetna Better Health of Pennsylvania brand, according to Pennsylvania’s Dept. of Human Services (DHS). Wessner’s suit claims that, in fraudulently exaggerating the amount of pediatric primary care doctors and the number of patients they served, Aetna was able to pocket an excessive margin of its capitated payments from the Medicaid program.

A recently unsealed whistleblower lawsuit accuses CVS Health Corp.’s Aetna of defrauding the Commonwealth of Pennsylvania and the federal Medicaid program by knowingly misrepresenting the number of pediatricians in Aetna’s Medicaid network. While the outcome of the suit is far from certain, and the Dept. of Justice opted not to intervene in the matter, legal experts say the case may have merit — and Medicaid insiders say that Aetna’s reputation may take a hit.

Carol Wessner, a nurse and former Early and Periodic Screening, Diagnostic and Treatment consultant for Aetna, alleges in a recently unsealed lawsuit that pediatric primary care was practically inaccessible to Aetna’s Medicaid members because of its incorrect provider directory. The insurer covered 265,868 Medicaid lives in 2020 under the Aetna Better Health of Pennsylvania brand, according to Pennsylvania’s Dept. of Human Services (DHS). Wessner’s suit claims that, in fraudulently exaggerating the amount of pediatric primary care doctors and the number of patients they served, Aetna was able to pocket an excessive margin of its capitated payments from the Medicaid program.

In a court filing, Wessner also claims that she made Aetna executives including Aetna Better Health CEO Jason Rottman and Director of Quality Management Alice Jefferson aware of the network’s shortcomings — and that they retaliated against Wessner by terminating her. In 2017, Wessner first filed a qui tam whistleblower complaint under the False Claims Act of 1863, which means that she would be entitled to a large portion of any settlement or damages Aetna might pay. During that time, federal prosecutors considered whether to join the case against Aetna.

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Broker Payment Transparency Rule May Trigger Policy Changes

September 17, 2021

So far this month, in addition to allocating hundreds of millions of dollars in federal funding to augment various aspects of the Affordable Care Act marketplaces, the Biden administration has also proposed a regulation that would increase transparency about how brokers are compensated for selling certain health plans. Health policy experts say that while those new requirements may not be particularly helpful for consumers, they could eventually trigger policymaking that alters some insurers’ broker payment practices.

The broker compensation provisions appear in a notice of proposed rulemaking (NPRM) issued jointly by HHS, the Labor and Treasury departments and the Office of Personnel Management — a large portion of which is devoted to establishing new data-reporting requirements for air ambulance services (which historically were a frequent source of surprise medical bills). In addition to those provisions, the NPRM proposes to require issuers offering individual health insurance coverage or short-term, limited duration insurance (STLDI) to “disclose to policyholders, before finalizing plan selection as well as on documentation confirming the individual’s enrollment, commission rates and compensation structure for other direct and indirect compensation provided by the issuer to an agent or broker associated with enrolling those individuals.”

So far this month, in addition to allocating hundreds of millions of dollars in federal funding to augment various aspects of the Affordable Care Act marketplaces, the Biden administration has also proposed a regulation that would increase transparency about how brokers are compensated for selling certain health plans. Health policy experts say that while those new requirements may not be particularly helpful for consumers, they could eventually trigger policymaking that alters some insurers’ broker payment practices.

The broker compensation provisions appear in a notice of proposed rulemaking (NPRM) issued jointly by HHS, the Labor and Treasury departments and the Office of Personnel Management — a large portion of which is devoted to establishing new data-reporting requirements for air ambulance services (which historically were a frequent source of surprise medical bills). In addition to those provisions, the NPRM proposes to require issuers offering individual health insurance coverage or short-term, limited duration insurance (STLDI) to “disclose to policyholders, before finalizing plan selection as well as on documentation confirming the individual’s enrollment, commission rates and compensation structure for other direct and indirect compensation provided by the issuer to an agent or broker associated with enrolling those individuals.”

The proposed rules would further require insurers to “report to HHS the actual, total amount of direct and indirect compensation paid by the issuer to the agent and broker for the preceding year.”

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Biden Unveils Sweeping Vaccine Mandates Amid Delta Variant Surge

September 17, 2021

To curb the surging delta variant, President Joe Biden last Thursday laid out coronavirus vaccine mandates that could affect tens of millions of Americans including federal workers, employees at large firms (like health insurance companies) and health care staff. Experts say the vaccines are highly effective at slowing the spread of the virus, saving lives and health care costs. A recent Health Affairs study suggested that by May 9, 2021, vaccination against COVID-19 may be associated with a reduction of nearly 140,000 deaths. Another Kaiser Family Foundation analysis estimated that between June and August 2021, over 280,000 COVID-related hospitalizations — costing over $5.7 billion combined — could have been prevented by vaccination. Almost 180 million Americans are fully vaccinated against the virus, yet new cases are still rising in recent weeks, most of which occurred among those not yet fully vaccinated, according to data from the Centers for Disease Control and Prevention.

by Jinghong Chen

To curb the surging delta variant, President Joe Biden last Thursday laid out coronavirus vaccine mandates that could affect tens of millions of Americans including federal workers, employees at large firms (like health insurance companies) and health care staff. Experts say the vaccines are highly effective at slowing the spread of the virus, saving lives and health care costs. A recent Health Affairs study suggested that by May 9, 2021, vaccination against COVID-19 may be associated with a reduction of nearly 140,000 deaths. Another Kaiser Family Foundation analysis estimated that between June and August 2021, over 280,000 COVID-related hospitalizations — costing over $5.7 billion combined — could have been prevented by vaccination. Almost 180 million Americans are fully vaccinated against the virus, yet new cases are still rising in recent weeks, most of which occurred among those not yet fully vaccinated, according to data from the Centers for Disease Control and Prevention.

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UnitedHealth Touts ASC Savings, But Are There Drawbacks?

September 17, 2021

A newly published report from UnitedHealthcare makes a strong financial case for moving routine, non-complex medical procedures — such as a gallbladder removal — from hospital outpatient departments to ambulatory surgery centers (ASCs). However, one industry observer cites a potential downside to shifting low-risk surgeries away from hospitals, and research suggests that access to ASCs is not equal across all populations.

For its report, UnitedHealthcare examined claims data from the insurer’s employer-sponsored plan members during the 12 months ending February 2020. Of the 6 million routine outpatient procedures that were performed in hospital outpatient departments for this population, 56% involved non-complex patients who had an ASC within a short distance from their homes. If such patients were to choose an ASC as their site of care, it would reduce the cost of routine procedures by an average of 59% — saving consumers $684 on average per procedure, according to UnitedHealthcare.

A newly published report from UnitedHealthcare makes a strong financial case for moving routine, non-complex medical procedures — such as a gallbladder removal — from hospital outpatient departments to ambulatory surgery centers (ASCs). However, one industry observer cites a potential downside to shifting low-risk surgeries away from hospitals, and research suggests that access to ASCs is not equal across all populations.

For its report, UnitedHealthcare examined claims data from the insurer’s employer-sponsored plan members during the 12 months ending February 2020. Of the 6 million routine outpatient procedures that were performed in hospital outpatient departments for this population, 56% involved non-complex patients who had an ASC within a short distance from their homes. If such patients were to choose an ASC as their site of care, it would reduce the cost of routine procedures by an average of 59% — saving consumers $684 on average per procedure, according to UnitedHealthcare.

Those estimated cost savings are attributable to the fact that surgeries performed at ASCs are well-known to be cheaper than those taking place at a hospital. According to the UnitedHealthcare report, the average price of common procedures performed in a hospital outpatient department in 2019 was $7,716, or 144% more than the average price of the same procedures performed in ASCs.

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News Briefs

September 17, 2021

Three centrist Democrats on the House Energy and Commerce committee on Sept. 15 voted down language in a bill that would have enabled Medicare to negotiate drug prices. Reps. Scott Peters (Calif.), Kathleen Rice (N.Y.) and Kurt Schrader (Ore.) joined the committee’s Republicans to keep the measure from advancing. Committee Chair Rep. Frank Pallone (D-N.J.) made several public appeals in favor of drug price negotiation to the trio, who according to Politico all voted in favor of Medicare price negotiation in 2019. Despite the setback, price negotiation is far from dead, according to James Gelfand, executive vice president of public affairs at the ERISA Industry Committee. “My understanding is that the bill can be completely rewritten in the Rules Committee if need be,” Gelfand tells AIS Health via email. He adds that Democratic leaders “have to offer something to Rice…I don’t know exactly what yet. But they cannot afford to blow a $5-600 billion hole in the bill before it gets to the Senate.”

Three centrist Democrats on the House Energy and Commerce committee on Sept. 15 voted down language in a bill that would have enabled Medicare to negotiate drug prices. Reps. Scott Peters (Calif.), Kathleen Rice (N.Y.) and Kurt Schrader (Ore.) joined the committee’s Republicans to keep the measure from advancing. Committee Chair Rep. Frank Pallone (D-N.J.) made several public appeals in favor of drug price negotiation to the trio, who according to Politico all voted in favor of Medicare price negotiation in 2019. Despite the setback, price negotiation is far from dead, according to James Gelfand, executive vice president of public affairs at the ERISA Industry Committee. “My understanding is that the bill can be completely rewritten in the Rules Committee if need be,” Gelfand tells AIS Health via email. He adds that Democratic leaders “have to offer something to Rice…I don’t know exactly what yet. But they cannot afford to blow a $5-600 billion hole in the bill before it gets to the Senate.”

After a plan member filed suit against CVS Health Corp.’s Aetna, accusing the payer of discriminating against LGBTQ+ members in fertility care reimbursement, the health plan announced plans to change its coverage. According to the National Women’s Law Center (NWLF), whose lawyers filed the complaint, “the suit alleges that Aetna’s policy for coverage of IVF and IUI fertility treatments unfairly discriminates against LGBTQ couples by requiring them to pay out of pocket for 12 cycles of IUI before Aetna will provide them with coverage.” NWLF told Modern Healthcare that “we are pleased to learn that there is interest in resolving the matter.”

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