CMMI Taking Hard Look at Medicare Advantage Coding Practices and Impact on Payment Models

The Center for Medicare and Medicaid Innovation (CMMI) wants to replace or improve its risk adjustment methodology after concerns of Medicare Advantage plans upcoding to get higher payments, the center’s director said. CMMI Director Liz Fowler, Ph.D., detailed how the center plans to shift the focus in its payment models to care delivery during a webinar Wednesday sponsored by the advocacy group United States of Care. The remarks come as scrutiny over MA coding practices has loomed over the lucrative market.

The Big Medicare Advantage Players Keep Getting Bigger

Six health insurers control roughly three-quarters of the fast-growing Medicare Advantage market, according to an Axios analysis of federal data. Medicare Advantage enrollment hasn’t slowed down in 2022, even though dismal projections from Humana and Cigna freaked out Wall Street earlier this month, and concentration at the top remains high. UnitedHealth Group had almost 7.9 million MA members as of Jan. 1, the most of any insurer and an 11% increase from the 7.1 million members it had at the same time in 2021, according to federal data. That means UnitedHealth captured roughly one out of every three people who joined Medicare Advantage this year.

HealthAxis Receives Growth Equity Investment from Revelstoke Capital Partners

Revelstoke Capital Partners (“Revelstoke”), a leading private equity firm focused on investing in healthcare companies, today announced a growth investment in HealthAxis Group, LLC (“HealthAxis”). HealthAxis delivers highly automated, next-generation Core Administrative Processing Solutions (“CAPS”), advanced analytics capabilities, and tech-forward services to healthcare payors. HealthAxis empowers healthcare payors and other risk-bearing organizations to accurately and efficiently process claims, administer benefits, manage providers, enroll participants, and support value-based contracts through mission-critical software and services.

HealthComp Acquires Gilsbar’s TPA Division

HealthComp Holding Company LLC (“HealthComp” or “the Company”), a New Mountain Capital company and a leading Third-Party Administrator (TPA) of healthcare benefits for self-funded employers, announced Monday that it has acquired Gilsbar’s TPA and Care Management (MedCom) divisions (Gilsbar, LLC). Together, the combined business will continue to deliver on two critical priorities for its clients: managing healthcare costs and delivering a best-in-class member experience. Gilsbar’s TPA offers a fully-integrated approach to benefit plan administration, which includes sophisticated technology and personalized service.

MedPAC: Majority of Medicare Beneficiaries to Be on MA by 2023, but Coding Issues Remain Rampant

Most Medicare beneficiaries in Parts A and B are expected to be enrolled in Medicare Advantage plans by next year, but spending on the plans is going to continue to outpace traditional fee-for-service, a congressional advisory panel found. The Medicare Payment Advisory Commission (MedPAC), a panel that makes recommendations to Congress on Medicare policy, released new findings Friday on the program, which has surged in popularity in recent years. It also continues to raise alarms over practices plans have done such as upcoding that have increased Medicare spending. MedPAC found 46% of beneficiaries in Parts A and B were enrolled in MA plans, and that figure is expected to stretch past 50% in 2023.

Nearly 1,300 MA Plans Offering Home-Focused Benefits for the Chronically Ill in 2022

New data relating to Medicare Advantage (MA) benefits is on its way out for the new year. And finally, it looks as if optimistic home-based care providers that view MA as a potential revenue stream in the near- and long-term future are seeing their bullishness validated. Just 267 MA plans offered Special Supplemental Benefits for the Chronically Ill (SSBCI) in 2020, but 1,292 will in 2022, according to new reporting from the Washington, D.C.-based research and advisory firm ATI Advisory. Compared to last year, 369 more plans will be offering these benefits in 2022.

CMS Looks for Guidance as Medicare Advantage Plans Struggle to Build Behavioral Health Networks

The Centers for Medicare and Medicaid Services is looking into why Medicare Advantage plans have apparently struggled to add behavioral health providers to their networks. Last week, CMS announced that it issued a proposed rule that would change how insurers operate Medicare Advantage and Medicare prescription drug plans. But within the same proposed rule, CMS also said that it was requesting information from industry stakeholders about why Medicare Advantage plans struggled to meet previously issued requirements to have behavioral health providers in their networks of providers.

Convey Health Solutions to Acquire HealthSmart International, a Home Healthcare Supplemental Benefits Company

Convey Health Solutions Holdings, Inc. (NYSE: CNVY) (Convey), a leading healthcare technology and services company, announced today that it entered into a definitive agreement to acquire HealthSmart International (HealthSmart) for $77.5 million in cash. The acquisition of HealthSmart will further expand Convey’s mission to provide industry leading solutions and services that improve health plan operations and elevate the member experience. HealthSmart’s health, wellness and diagnostic products centered on home-based care will accelerate Convey’s capabilities to improve health outcomes through innovative supplemental benefits.

WindRose Health Investors Completes the Sale of basys to BPOC and Five Arrows Capital

WindRose Health Investors, LLC (“WindRose”), the New York-based healthcare private equity firm, announced today that it has completed the sale of basys, LLC (“basys”) to BPOC and Five Arrows Capital. Following the sale, basys merged with Innovative Software Solutions Inc. (“ISSI”) to form a leading multiemployer benefits administration solutions provider. Harbour Benefits Holdings, Inc., the former owner of ISSI and the parent company of Zenith American Solutions, will retain an investment in the new organization. basys is a provider of specialized business administration software for the Taft-Hartley community, providing technology solutions for fund offices, national multiemployer plans, and third party administrators across the United States and Canada.

Nomi Health Acquires Artemis Health to Accelerate Transformation of U.S. Healthcare with Actionable Insights

Nomi Health, the leading direct healthcare provider in America, announced Thursday its acquisition of healthcare analytics provider Artemis Health — the partner of choice for more than 500 U.S. employers and benefits advisors to make health benefits higher quality and more affordable using data. The transaction gives Nomi Health customers actionable, data-driven insights to materially lower costs and improve the quality of care they deliver to their communities. Based in Salt Lake City, Artemis Health is the go-to partner for more than 500 employers, benefits advisors and health plans, including Intuit, US Foods, Paychex, GE Appliances, and J.B. Hunt.