September 15, 2023
MARI DEVEREAUX
More hospitals will face readmissions penalties in 2024, a departure from the lower rates of reimbursement cuts providers saw last year, according to preliminary data released Thursday.
While the Centers for Medicare and Medicaid Services has resumed use of its pneumonia readmissions measure, which was excluded last year from its Hospital Readmissions Reduction Program, payment adjustments have not returned to pre-pandemic levels.
September 07, 2023
NONA TEPPER
Some health insurance companies are rethinking prior authorization amid a groundswell of complaints from patients and providers and intensifying government scrutiny.
Health insurance companies employ prior authorization rules to constrain costs and to limit unnecessary care, much as insurers place limits on coverage in other ways. Yet big players such as UnitedHealth Group, Cigna and several Blue Cross and Blue Shield companies have announced plans this year to relax their precertification policies. Provider groups have applauded these announcements, albeit cautiously.
August 09, 2023
MARI DEVEREAUX
The Centers for Medicare and Medicaid Services is revising its patient experience survey to address low response rates and expand data on care quality.
Announced Aug.1 as part of the agency’s inpatient prospective payment system final rule, the modifications to the Hospital Consumer Assessment of Healthcare Providers and Systems survey have been years in the making.
Before the COVID-19 pandemic, stakeholders advocated for CMS to improve the HCAHPS survey by changing its response format and fine-tuning the measures included. Now, with more patients reporting declines in their hospital experiences, CMS is sharpening its focus on improving the survey process.
July 25, 2023
NONA TEPPER
Two Cigna members filed a lawsuit seeking class-action status in a California federal court on Monday, alleging the health insurance company leveraged an algorithm to improperly deny claims and systematically shift costs to its 2.1 million Golden State members. Lawyers anticipate more insurers will be hit with similar complaints as carriers increasingly automate their claims management processes.
Enrollees Suzanne Kisting-Leung and Ayesha Smiley sued Cigna in the U.S. District Court for the Eastern District of California, alleging the company used an algorithm called PXDX to review patient claims, which violated its fiduciary duty dictated by state law.
June 29, 2023
KARA HARTNETT
The Supreme Court ruling that higher education institutions may not consider race when making admission decisions could have far-reaching consequences for the healthcare industry.
The ruling issued Thursday applies to public and private schools that receive federal funding and culminates legal challenges to the admissions polices at the University of North Carolina and Harvard University. In 2014, applicants sued the colleges, arguing that applying affirmative action to admissions unfairly diminished their chances of being accepted. The Supreme Court’s conservative majority ruled 6-3 in their favor.
June 29, 2023
ALEX KACIK
Healthcare costs are expected to rise 7% next year as providers deal with higher expenses and seek rate increases during contract negotiations with insurers.
The projection by PricewaterhouseCoopers’ Health Research Institute tops the consultancy’s estimates in 2022 and 2023, which were 5.5% and 6%, respectively.
For their annual report, PwC researchers spoke with actuaries who work with insurers covering 100 million employer-sponsored members and 10 million Affordable Care Act members to forecast healthcare inflation. The results were weighted by each health plan’s size.
June 28, 2023
Associated Press
WASHINGTON — The Justice Department has charged dozens of people in several healthcare fraud and prescription drug schemes, including one totaling $1.9 billion and a doctor accused of ordering fake ankle braces for a patient whose leg had been amputated, officials said Wednesday.
The scheme involving the submission of nearly $2 billion in bogus claims is one of the largest healthcare fraud cases ever brought by the Justice Department, the agency said. It’s one of several announced as part of a crackdown in states around the country.
Yakima Valley Memorial Hospital in Washington settles breach that affected 419 people
June 15, 2023
Today, the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) announced a settlement with Yakima Valley Memorial Hospital, a not-for-profit community hospital located in Yakima, Washington resolving an investigation under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OCR investigated allegations that several security guards from Yakima Valley Memorial Hospital impermissibly accessed the medical records of 419 individuals. HIPAA is a federal law that protects the privacy and security of protected health information. The HIPAA Privacy, Security, and Breach Notification Rules apply to most health care organizations and set the requirements that HIPAA-regulated entities must follow to protect the privacy and security of health information.
June 14, 2023
VICTORIA TURNER
National health expenditures will surpass $7 trillion and consume nearly one-fifth of the U.S. economy in 2031, according to projections the Centers for Medicare and Medicaid Services’ Office of the Actuary published Wednesday.
Healthcare spending will rise by an average of 5.4% a year from 2022 through 2031, when it will reach $7.17 trillion, or 19.6% of gross domestic product. “Health spending over the course of the next 10 years is expected to grow more rapidly, on average, than the overall economy,” CMS actuaries wrote in the journal Health Affairs.
June 08, 2023
NONA TEPPER
Medicaid beneficiaries have the right to sue state agencies they allege break federal law, the Supreme Court ruled Thursday.
The 7-2 decision reaffirms previous precedent that U.S. District Court for the Northern District of Indiana challenged in 2020 when it dismissed a case against a county-owned nursing home accused of violating federal patient protection laws. The high court decision upholds a 2021 ruling by the U.S. Court of Appeals for the 7th Circuit. The case now returns to the district court.
