Ever since the COVID-19 public health emergency (PHE) was declared in 2020, telehealth billing rules have changed repeatedly, making it difficult to keep up. While many telehealth flexibilities are still in place, some will be going away effective January 1, 2025. That’s the word from the2025 Medicare Physician Fee Schedule Final Rule, which CMS released on November 1....
Hospital-at-home and telehealth reimbursement from CMS will expire at the end of 2024 without congressional action. Here are five things to know about what the CMS and Congress need to do to extend reimbursement for these programs.
Accountable care organizations in the ACO Reach program...
The Centers for Medicare and Medicaid Services (CMS) is moving forward with a 2.9% cut to physician payments in 2025 despite protest from major industry groups. CMS announced Friday it finalized the calendar year 2025Medicare Physician Fee Schedule rulethat sets payment rates for next year and also outlines new policies focused on primary care, preserved telehealth...
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.
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