RISE summarizes recent regulatory-related headlines.
UnitedHealth joins Humana in support of MA billing practice changes
UnitedHealth Group said it wants to partner with policymakers to develop solutions that reduce overall health care costs, provide stability for the Medicare Advantage program, and promote access to high-quality, coordinated care for seniors.
The country’s largest Medicare Advantage insurer published a statement on its website last week that indicated its support for changes to lucrative billing practices related to in-home clinical visits. The one-hour nurse visits to Medicare recipients' homes provided Medicare Advantage insurers with $15 billion in extra payments from 2019 to 2021, according to a Wall Street Journal investigation last year.
RELATED: WSJ: Humana backs proposals to limit MA billing practices that cause extra payments
In a recent follow-up article, the Wall Street Journal reported that Humana, the second-largest Medicare Advantage insurer, had been working on proposed reforms and steps lawmakers could take to address the potential misuse of home visits. The company supports changing billing practices so that insurers are only paid for the diagnoses in insurer-initiated home visits if they are documented elsewhere and receive payment for diagnoses from chart reviews if they are linked to specific medical encounters.
UnitedHealth also said that it supports modernizing and strengthening Medicare Advantage. However, it said the in-home clinical visits are a critical access point to the health care system that meets seniors where they are and supports a holistic understanding of their health care needs. The insurer says it “supports policies that hold in-home clinical visits to the highest standard and are supportive of a wide range of solutions that modernize in-home clinical assessments.” Those actions include:
Ensuring beneficiaries who receive new diagnoses during an in-home clinical visit have follow-up care within specific timeframes and standards. For instance, excluding new diagnoses identified during an in-home HRA unless a diagnosis has been reviewed by a provider within 18 months or the CMS data submission window.
- Requiring health plans to connect beneficiaries to care coordination programs and benefits.
- Standardizing in-home clinical assessments to adhere to CMS’ 2016 Best Practices.
- Strengthening program oversight and integrity through enhanced reporting and transparency.
- Deploying annual audits focused on in-home clinical visits.
MA plans will receive $12.7B in quality bonus payments
Estimated bonus payments to Medicare Advantage plans will total at least $12.7 billion in 2025, similar to 2023, according to a new KFF brief.
The quality bonus program increases Medicare payments to Medicare Advantage plans based on a five-star rating system. Plans may, but are not required to, use the additional payments to cover the cost of supplemental benefits, including reduced cost sharing and extra benefits not covered by traditional Medicare.
The KFF brief analyzes trends in bonus payments to Medicare Advantage plans, enrollment in plans in bonus status, and how these measures vary across plan types using publicly available information on Medicare Advantage enrollment, payment rates, and quality ratings.
The report finds
- Federal spending on Medicare Advantage bonus payments will total at least $12.7 billion in 2025, similar to spending in 2023, and more than four times higher than in 2015.
- Most Medicare Advantage enrollees (75 percent) are in plans that are receiving bonus payments in 2025.
- The average bonus payment per enrollee is highest for employer- and union-sponsored Medicare Advantage plans ($438) and lowest for special needs plans ($332).
Report: CDC to reinstate approximately 400 laid-off workers
Politico reports that the Centers for Disease Control and Prevention (CDC) sent an email to staff that it will reinstate more than 400 people who had received layoff notices as part of U.S. Health Secretary Robert F. Kennedy Jr.’s overhaul of the Department of Health and Human Services (HHS). Approximately 2,400 employees were laid off at CDC.
Half of the reinstated employees include those who worked at the National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention, according to the article. Approximately a third worked for the National Center for Environmental Health.
Politico said other divisions looking to reinstate employees include the National Center for Health Statistics, Center for Forecasting and Outbreak Analytics, Office of Human Resources, Global Health Center, Office of Acquisition Services, and Office of Communications.
In a statement to ABC News on Wednesday, an HHS spokesperson confirmed the reinstatements: "Under Secretary Kennedy's leadership, the nation's critical public health functions remain intact and effective… The Trump Administration is committed to protecting essential services—whether it's supporting coal miners and firefighters through NIOSH, safeguarding public health through lead prevention, or researching and tracking the most prevalent communicable diseases," the spokesperson said.
GAO report calls for coordinated federal approach to prepare for next pandemic
A recent report by the Government Accountability Office (GAO) calls on HHS to develop a national diagnostic testing strategy and establish a national testing forum in preparation for the next pandemic threat.
The GAO said that during COVID-19, HHS struggled to lead the nation’s testing efforts, which required close coordination with public and private stakeholders. As a result, GAO conducted a roundtable of 19 experts to discuss ways HHS could improve testing and offered four recommendations:
- Develop a national diagnostic testing strategy for infectious diseases with pandemic potential.
- Periodically update the national diagnostic testing strategy to incorporate any future lessons learned from infectious disease threats with pandemic potential.
- Establish a national diagnostic testing forum for infectious diseases with pandemic potential. The forum should include key decision-makers and facilitate two-way discussion.
- Ensure the national diagnostic testing forum meets regularly, including both before and during infectious disease threats with pandemic potential.