JustCare

Category: What’s Buzzing

  • Medicare adds $25+ billion to Medicare Advantage insurer coffers

    Medicare adds $25+ billion to Medicare Advantage insurer coffers

    The Centers for Medicare and Medicaid Services just announced the final rule regarding Medicare Advantage payments in 2026. Notwithstanding $83 billion in overpayments to MA insurers last year and  this year as well, the Trump Administration opted to increase insurer payments by $25+ billion in 2026.

    The payment increase of 5.06 percent is more than double the proposed increase of 2.23 percent in the Biden administration’s Advance Notice for MA payments in 2026. To be clear, increases in payments to Medicare Advantage insurers end up largely in the form of profits for the insurers, but they also allow the insurers to market “additional benefits” to people with Medicare.

    Beware: If you are enrolled in a Medicare Advantage plan and you are diagnosed with a complex and costly condition, you might not be able to see the specialists you want to see or use the hospitals you want to use. Moreover, you may face inappropriate delays and denials of care. If you want easy access to care, you should enroll in traditional Medicare.

    The serious problem with any payment increase is that the Medicare Advantage insurers are expected to be overpaid more than $1 trillion in the next 10 years. The result is that people with Medicare will be forced to pay $220 billion more in Medicare premiums over the next ten years. Medicare premiums are calculated based on program costs.

    What’s equally concerning is that the Medicare Trust Fund is projected to lose $550 billion over the next ten years as a result of government overpayments to insurers.

    The Centers for Medicare and Medicaid Services claims that the additional boost to MA insurers stems from higher costs in the last quarter of 2024.

    On a happier note, CMS is finalizing the third and last year of the proposed change to the Medicare Advantage “risk-adjustment model” for paying insurers that the Biden administration launched in 2024. The changes are intended to eliminate some of the gaming that insurers engage in to collect more from the government for their services than appropriate.

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  • 2025: Government finalizes new Medicare Advantage policies

    2025: Government finalizes new Medicare Advantage policies

    Last Friday, the Centers for Medicare & Medicaid Services (CMS) issued a final rule regarding Medicare Advantage (MA) and Medicare Prescription Drug (Part D) policy. The rule will take effect in 2026. Of note, the final rule does not call for Medicare coverage of Ozempic or other anti-obesity drugs for people seeking to lose weight, as proposed, nor does it put guardrails on insurers’ use of artificial intelligence to deny care.

    CMS chose not to finalize provisions in the Biden Administration’s proposed rule related to promoting equity, ensuring equitable access to MA services, imposing guardrails for artificial intelligence (AI) or covering anti-obesity medicines.

    The rule does require MA plans to cover inpatient hospital admissions that they approved based through a prior authorization process. MA plans have too often decided post prior authorization approval to deny coverage for inpatient admissions that they deemed, after the fact, should have been treated as outpatient admissions. MA plans can only reopen a prior approval of an inpatient admission because of fraud or administrative error.

    CMS also finalized a rule ensuring that enrollees and providers can appeal an MA denial whether it comes before, during or after a procedure.

    CMS finalized a proposal that prohibits Medicare Part D plans from charging a deductible or copay for adult vaccines that the Advisory Committee on Immunization Practices recommends. The deductible also does not apply to insulin products; and, cost-sharing for these products cannot go above $35.

    In addition, Part D plans must allow enrollees to make monthly payments for their covered drugs over the course of the year, rather than in one lump sum at the pharmacy. Effective this year, these payments cannot exceed $2,000 over the course of the year.

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  • AI can second-guess physicians and improve care

    AI can second-guess physicians and improve care

    Regardless of what we think about the benefits of using artificial intelligence (AI) for medical treatment, physicians are now using AI in a variety of ways. One way that AI can benefit patients is by second-guessing patients. Alvin Powell reports for the Harvard Gazette on how AI is beginning to reduce human suffering.

    Sometimes, patients have such rare conditions that physicians are hard-pressed to diagnose them properly. But, if the physician puts their symptoms into a well-working Large Language Model (LLM), AI, it can answer a wide range of questions. And, the patient can get treated appropriately.

    Powell gives the example of seeing a rare condition in a child. The physician asked AI a range of questions, the “genetic causes, biochemical pathways, next steps in the workup, even what to tell the child’s parents.” AI made the physician’s job efficient and effective.

    To be clear, AI cannot work alone. We still need physicians. But, lay people can get helpful answers on medical conditions. And, AI can successfully second-guess physicians. For example, AI diagnosed a child’s pain correctly after 17 physicians had failed to do so over three years.

    The child’s mom gave ChatGPT all of her child’s medical notes. And, ChatGPT correctly determined the child’s spinal cord was attaching to his backbone. With that accurate diagnosis, a surgeon could treat the problem.

    AI also should be able to allow physicians to see more patients, helping physicians with patients’ histories, possible diagnoses etc. One experiment using AI found that doctors who entered all information into an LLM and left it to the AI to determine the diagnosis had a 90 percent accuracy rate, as compared to the doctors not relying on AI at all, who had a 74 percent accuracy rate.

    One physician with AI expertise explains: “The best way a doctor could use it now is for a second opinion, to second-guess themselves when they have a tricky case,” he said. “How could I be wrong? What am I missing? What other questions should I ask?

    But, physicians can also use AI to understand and prevent harmful drug interactions in hospital. Today, as many as one in four hospitalized patients in Massachusetts suffer from bad side effects. Using AI, they can be avoided.

    And, physicians can use AI for good note-taking while speaking with a patient. Rather than looking into a computer as they discuss the patient’s condition, AI can do the work, writing up and summarizing the clinical notes. The physician need only review the notes for accuracy, easing the physician’s workload.

    Still, AI can spit out bad information. So, physicians who rely on it need to be mindful.

    Here’s more from Just Care:

  • Medicare Advantage costs and prior authorization rules impede access to care

    Medicare Advantage costs and prior authorization rules impede access to care

    Medicare Advantage costs and prior authorization rules continue to impede access to care. Anyone enrolled in a Medicare Advantage plan–Medicare coverage administered by a corporate health insurer–should be concerned about whether they will be able to get and afford the care they need if they get sick. Traditional Medicare provides coverage for care from almost any physician or hospital in the US without the need for prior authorization.

    Jakob Emerson reports for Beckers Payer that typical deductibles for Medicare Advantage plans are now more than twice what they were in 2024. It’s fair to assume that they will continue to rise, given the Trump administration’s full court press on government spending. You’ll be fine in Medicare Advantage if you’re healthy, but you’ll likely be far better off in traditional Medicare if you want to ensure you’ll be able to afford and receive the care you need when you get sick.

    Average Medicare Advantage deductibles were about $132 in 2024 and are now $315, according to an eHealth survey. That’s a 139 percent increase. Monthly premiums average just $5 a month this year, down from $9 in 2024. And, total out-of-pocket costs for covered in-network services can be as high as $9,350 this year, depending upon the Medicare Advantage plan.

    Average Medicare Part D prescription drug coverage premiums are also up, from $29 to $36, about 25 percent.

    Meanwhile, prior authorization rules remain another obstacle to care for Medicare Advantage enrollees, particularly those who need costly and complex care. Rylee Wilson reports for Beckers Payer that some states are looking into regulating insurers’ use of prior authorization. They are especially focused on insurers’ use of artificial intelligence or AI to determine whether a procedure should be covered and want a physician to oversee those decisions. (Could  that simply mean a physician rubber-stamping them?)

    Patients are currently suing UnitedHealth and Humana for using AI to deny rehab care in Medicare Advantage inappropriately. UnitedHealth spokespeople argue that they do not use AI exclusively to make coverage decisions. They might not, though having a provider oversee these decisions with financial and other incentives to approve them is no better than using AI exclusively.

    Last year, the Centers for Medicare and Medicaid Services, CMS, which oversees Medicare, issued guidance on the use of AI in Medicare Advantage. CMS did not ban the use of AI or even restrict it. It simply said that the AI algorithm must comply with Medicare’s coverage requirements. Good luck enforcing that rule.

    Dr. Mehmet Oz, who will head of CMS, once confirmed, believes in AI as a tool for expediting prior authorization decisions–seemingly, even though they can speed up inappropriate denials. However, Oz says that insurers should not use AI for more than 1,000 procedures.“I would argue that to use AI wisely, we would make a decision which is we’re only going to pre-authorize 1,000 procedures,” he said at a recent Senate hearing. Where he pulled the 1,000 number from is anyone’s guess.

    Here’s more from Just Care:

  • How much profit should shareholders reap from health care?

    How much profit should shareholders reap from health care?

    A group of Yale researchers looked at where all the profits from the health care industrial complex flow. They found that the vast majority of money earned by pharmaceutical corporations, for-profit hospitals, health insurers and other publicly traded companies went to corporate shareholders, reports Sujata Srinavasan for Connecticut Public Radio.

    In the 21 years between 2001 and 2022, the researchers found that $2.6 trillion went to shareholders. Their study is published in JAMA Internal Medicine. The number is shocking for at least three reasons. First, the $2.6 trillion represents 95 percent of the profits. Second, only five percent of the money went to medical research and development, improved hospitals or pharmaceutical research. Third, the returns to shareholders more than tripled over that period.

    Given how much Americans pay for health care and the burden of medical debt on millions of us, it’s time for the government to rein in the prices we are being charged or, at the very least, limit corporate profits with the goal of lowering costs. Today, about 12 percent of adults in the US owe more than $10,000 in medical debt. Should there be a limit on corporate profits to reduce health care costs?

    With increasing vertical integration in health care, e.g. UnitedHealth owning providers, a pharmacy benefit manager, claims processing centers, insurance companies and more, unless there is a limit on corporate profits, it’s more than likely that health care costs will continue to mount. Health care corporations are not putting patients first.

    Corporate shareholder returns are not the only funds being stripped out of our health care system and driving up costs. The researchers did not look at the $1 trillion that private equity firms invested in health care over the last decade. These companies have destabilized a large number of hospitals, taking out profits and leaving them in major debt. They have also profited wildly from investments in home care agencies at the expense of older adults.

    Here’s more from Just Care:

  • DOJ takes on health insurers for price-fixing

    DOJ takes on health insurers for price-fixing

    In a significant move, the DOJ filed a “statement of interest” in federal court this week, siding with hundreds of physicians who accuse top insurers and a firm formerly known as MultiPlan — now rebranded as Claritev — of conspiring to fix prices for out-of-network care.

    The DOJ’s involvement doesn’t just add legal firepower. It sends a signal that this case matters. More importantly, it casts a harsh spotlight on how major insurers including UnitedHealthcare, Aetna, Cigna and Elevance may have skirted antitrust laws through a so-called “third-party intermediary” — and whether Wall Street has been too confident in the impunity these corporations usually enjoy.

    According to reports, the DOJ rebuffed Claritev’s argument that there was no price-fixing conspiracy simply because insurers may use the company’s algorithm differently. The Sherman Antitrust Act, the DOJ pointed out, is clear: even setting a “starting point” for prices — if done in coordination — can be anti-competitive. And sharing sensitive pricing data through a middleman? That’s also potentially illegal.

    As someone who spent years inside the health insurance industry, I can tell you that what’s at stake here is nothing short of enormous. If this lawsuit proceeds, we might finally get a clearer picture of how these corporations — working together under the cover of a “neutral” analytics firm — manipulated payment rates to increase profits, all while starving frontline health care providers.

    Claritev and its insurer partners, of course, deny the allegations and have moved to dismiss the case. But the DOJ’s filing now stands in their way.

    Some history: The backstory adds even more weight to the DOJ’s action. In 2023, a New York Times investigation uncovered how Claritev (then MultiPlan) operated under a perverse incentive: the more it “saved” insurers and their corporate clients by underpaying doctors, the bigger the cut Claritev and insurers took for themselves. That same year, Senator Amy Klobuchar called on federal regulators to investigate what she and many providers viewed as algorithm-enabled price-fixing. She even introduced legislation to stop corporations from using AI tools to coordinate pricing.

    The DOJ statement of interest comes just weeks after the agency launched an investigation into UnitedHealth Group’s Medicare billing practices. As the Wall Street Journal reported, the DOJ “is examining the company’s practices for recording diagnoses that trigger extra payments to its Medicare Advantage plans, including at physician groups the insurance giant owns.”

    For years, insurers have been able to hide behind complex data systems, AI algorithms and opaque contracting practices to squeeze providers — and boost profits. Investors have generally assumed that neither Congress nor federal regulators would seriously challenge that model.

    But this latest move by the DOJ suggests otherwise. Maybe — just maybe — the Trump Administration will be tougher on insurers than investors expected. And if that is true, it would be a long-overdue course correction – for doctors, patients and taxpayers.

    [Note: This post was originally published on Wendell Potter’s Substack, HEALTH CARE un-covered.]

    Here’s more from Just Care:

  • Republicans look to end Medicare Advantage overpayments

    Republicans look to end Medicare Advantage overpayments

    More members of Congress on both sides of the aisle are looking at ways to end massive overpayments to Medicare Advantage insurers as a means of reducing federal spending, reports Peter Sullivan for Axios. Ending these overpayments should not affect people’s Medicare benefits, it would simply put spending in Medicare Advantage for each enrollee on a par with spending in Traditional Medicare. In sharp contrast, cutting Medicaid benefits would likely cause tens of millions of Americans to become uninsured or underinsured.

  • Few psychiatrists accept Medicare

    Few psychiatrists accept Medicare

    If you and your spouse are not working, you likely need to enroll in Medicare at 65. But, as with many health insurance policies, it is extremely difficult to find psychiatrists who will accept Medicare coverage, reports Eugene Rubin, M.D. for Psychiatry Today.

    A study by John Havlik et al., reported in JAMA Network, finds that just over 18,000 psychiatrists were willing to bill Medicare for their services, out of a total of more than 56,000 psychiatrists nationwide.  The number willing to bill Medicare decreased by nearly 4,000 over eight years between 2014 to 2022.  That’s a 16.8 percent decrease in the number of shrinks willing to bill Medicare. Overall, only about one in three psychiatrists take Medicare.

    The researchers could not study the number of psychiatrists who contract with Medicare Advantage plans. But, overall, fewer physicians agree to work with Medicare Advantage plans than traditional Medicare. And, Medicare Advantage plans do not tout their great mental health coverage. So, it’s more than likely that it’s even harder to see a shrink in Medicare Advantage than in traditional Medicare.

    Other research has shown that people with Medicare can wait up to six months to see a therapist. But, Medicare now covers mental health care from marriage and family therapists, mental health counselors, and drug addiction specialists, as well as psychiatrists, psychologists, psychiatric nurses and licensed clinical social workers, increasing the pool of mental health providers available for people with Medicare.

    People with employer coverage and in state health insurance plans also struggle to get insurance coverage for visits to the shrink. Fewer than three in five shrinks accept any health insurance.

    To be clear, access to Medicare coverage for visits to the shrink differs depending on where you live. In Wyoming, for example, there are just 13.8 shrinks who take Medicare for every 100,000 people with Medicare, in Mississippi, 22.1 shrinks, and Montana, 27.4 shrinks. In Rhode Island, there are 174.7 shrinks for every 100,000 people with Medicare. In nine states, there are fewer than 40 shrinks for every 100,000 people with Medicare.

    While Medicare Part B covers mental health services for people enrolled in Medicare Advantage and traditional Medicare, the federal mental health parity laws do not apply to Medicare. They should!

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  • Medicaid is a benefit for the middle-class

    Medicaid is a benefit for the middle-class

    Many people do not appreciate how important Medicaid is for middle-class families, reports Ron Lieber for the New York Times. While Medicaid benefits tens of millions of lower-income families, middle-income families often end up relying on Medicaid as they spend down their savings.

    Medicaid pays for nursing home and at-home care for people nearing the end of life who have exhausted their savings. It also provides health insurance to young people who are no longer eligible to be on their parents’ health insurance policies and are not yet making enough income to buy their own insurance. And, it provides health coverage to people with disabilities.

    Few Americans should assume that they or their loved ones won’t need Medicaid at some time in their lives. All it takes is one expensive health care condition and you can deplete your assets enough to qualify for Medicaid. Today, more than 72 million Americans are enrolled in Medicaid, and many more who qualify for Medicaid are not enrolled because of how complicated it can be to qualify.

    Medicaid is an extremely valuable safety net for all of us. And, right now, it is on the chopping block!

    What does Medicaid pay for? Nursing home care and at-home long-term care (which Medicare does not pay for) for people who have spent most of their savings (excluding the value of their homes.) Medicare only pays for limited skilled nursing and at-home care for people who are homebound and otherwise meet the eligibility requirements. This care is unaffordable for most Americans. Nursing home care now easily costs more than $100,000 a year for a semi-private room.

    Medicaid also offers health insurance to people with yearly incomes under $21,597. Eligibility turns on the state you live in, some of which are more generous than others.

    And people with disabilities who are unable to work are often covered by Medicaid, if their assets are low. Medicaid allows families members to continue to work. Without Medicaid, most people must rely on family caregivers, who are forced to quit their work to care for their loved ones.

    What can you do? It’s not yet clear whether Republicans will cut Medicaid. If they do, it’s likely that millions of Americans will be uninsured or underinsured. Americans should contact their representatives in Congress to let them know how grateful they are for Medicaid and urge them not to cut Medicaid.

    Moreover, Republicans do not have to cut Medicaid. If they want to reduce federal spending to pay for tax cuts for wealthy Americans, they have a choice. Republicans should end the waste and overpayments in Medicare Advantage, which the Congressional Budget Office estimates to total $1 trillion over the next decade.

    Here’s more from Just Care:

  • UnitedHealth overbills the VA by hundreds of millions of dollars

    UnitedHealth overbills the VA by hundreds of millions of dollars

    At a recent Congressional hearing in Washington, Rep. Mark Takano (D-California), the top Democrat on the House Veterans Affairs Committee, directed a series of questions to the CEO of the health care company Optum, a wholly owned subsidiary of UnitedHeath Group. The exchange helped expose an alarming and growing problem in veterans’ health care in this country: massive overbilling by large, for-profit insurance conglomerates.

    Takano’s questioning was a master class, and you should watch it. You can see a taste of it here.

    What Rep. Takano exposed is that massive health care companies are enriching themselves at the expense of our nation’s Veterans.

    At issue is the Veterans’ Community Care Program, which facilitates medical care for veterans provided by health care professionals outside of the Veterans Health Administration (VHA).

    The program is administered by big health insurance companies, including Optum and TriWest. Data compiled by federal investigators shows that these insurers, often called third-party administrators (TPAs), overbill the government in a similar way that insurers selling Medicare Advantage plans do, as HEALTH CARE uncovered has reported.

    Department of Veterans Affairs Office of the Inspector General (OIG) February 2025 report.

    The investigators looked under the hood of these companies and found some real troubling signs. Their February 2025 report – published by the Department of Veterans Affairs Office of the Inspector General (OIG) – found that the VHA overpaid its TPAs by more than $1 billion between 2020 and 2024.

    The largest recipient was UnitedHealth Group’s Optum, which received overpayments of more than $105 million from 2020 to 2022. TriWest was overpaid $73.4 million from 2020 to 2023. The OIG found the overpayments were a result of the companies charging the VHA incorrect rates.

    For example, Optum reportedly overcharged the VHA by $783.4 million between 2020 and May 2024 for dental services provided by community care providers. Investigators said Optum was able to charge the extra amount because of a technicality in the contract: there was no language that specifically prevented Optum from charging the VHA more than it was reimbursing the community care provider for the service.

    It turns out this is not a new problem. An OIG report from 2021 found that providers providing care for veterans through the Community Care Program billed for higher paying evaluation and management services codes at much higher rates than other doctors in the same specialty. That’s evidence of upcoding. The report also found that providers were potentially double billing for services provided by entering additional codes already covered by a global surgery code. These additional codes cost the VA $59.6 million from between 2020 and 2022.

    Kudos to Rep. Takano for raising this important issue and his efforts to protect the integrity and solvency of the VA program and hold the insurance companies accountable.

    [This post was originally published on March 18, 2025 on Health Care un-covered.]

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