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Payer - UnitedHealth, DOJ to discuss Amedisys deal + more · Becker’s Payer Issues Podcast

• 0:00
  This is Jacob Emerson with the Becker's Payer
• 0:02
  Issues podcast.
• 0:03
  Here's your industry news briefing for October 28th.
• 0:08
  UnitedHealth Group representatives are set to meet with
• 0:10
  Justice Department officials to make the case for
• 0:13
  the company's acquisition of Amedisys to be approved.
• 0:17
  That meeting is often the last step before
• 0:19
  the DOJ decides whether to file a lawsuit
• 0:21
  challenging an acquisition.
• 0:23
  Amedisys provides home health, hospice, and high acuity
• 0:26
  care. It operates more than 500 facilities across
• 0:30
  37
• 0:31
  states. Amedis' shareholders approved that acquisition back in
• 0:35
  September of 2023.
• 0:37
  The deal has been held up by regulatory
• 0:39
  scrutiny. DOJ officials are concerned the deal could
• 0:42
  increase prices for home health services.
• 0:45
  UnitedHealth also acquired LHC Group, a home health
• 0:48
  provider with more than 900 locations
• 0:50
  back in February 2023.
• 0:53
  If the acquisition of Amedisys is approved, the
• 0:55
  company would own 10% of the home health
• 0:58
  market, UnitedHealth that is, with significant overlap between
• 1:01
  Amedisys and LHC Acquisitions in some southern states.
• 1:05
  Regulators could approve the deal with some changes
• 1:08
  to address competition concerns.
• 1:10
  In August, Amedisys and UnitedHealth agreed to sell
• 1:13
  an undisclosed number of care center care centers
• 1:16
  to Vital Caring Group if the merger is
• 1:19
  approved.
• 1:21
  Well, Medicare Advantage companies are bringing in 1,000,000,000
• 1:24
  in questionable payments found during in home visits
• 1:27
  and chart reviews. That's according to HHS's office
• 1:30
  of inspector general in a new audit. That
• 1:32
  report was published October 24th, and the federal
• 1:35
  watchdog estimated that MA companies received 7 and
• 1:39
  a half $1,000,000,000
• 1:40
  in payments through health risk assessments and chart
• 1:42
  reviews.
• 1:43
  The watchdog wrote that questionable use of HRAs
• 1:46
  is driving up payments to plans.
• 1:49
  MA plans conduct HRAs to collect information about
• 1:52
  enrollee health status.
• 1:54
  These assessments are sometimes conducted by providers as
• 1:57
  part of beneficiaries
• 1:58
  annual wellness visits or in their homes. MA
• 2:01
  plans also conduct
• 2:03
  chart reviews to find diagnoses that may have
• 2:05
  been missed by providers during visits.
• 2:08
  CMS found that 1,700,000
• 2:10
  Medicare Advantage enrollees with diagnoses from HRAs and
• 2:13
  chart reviews
• 2:14
  were not substantiated
• 2:15
  by any other
• 2:17
  visits, procedures, or tests in their medical records.
• 2:21
  Diagnoses reported only on an HRA conducted at
• 2:24
  any setting, but on no other service records,
• 2:26
  raise questions about whether the diagnoses are valid
• 2:29
  and whether enrollees got needed care according to
• 2:32
  the reports.
• 2:34
  UnitedHealth Group stood out from its peers in
• 2:36
  its in in its use of in home
• 2:38
  visits and chart reviews to generate payments according
• 2:40
  to the OIG.
• 2:42
  United is also the largest Medicare Advantage provider
• 2:44
  and receives $3,700,000,000
• 2:46
  in risk adjustment payments from HRAs and chart
• 2:48
  reviews in 2023.
• 2:51
  In a statement shared with Becker's, a UnitedHealthcare
• 2:53
  spokesperson said that the report is a misleading,
• 2:56
  narrow, and incomplete view of risk adjustment data
• 2:59
  and is being used to draw inaccurate conclusions
• 3:01
  about the value of in home care for
• 3:03
  MA beneficiaries.
• 3:07
  Well, Kodiak Solutions says that its analysis of
• 3:09
  hospital inpatient and outpatient claims data suggests that
• 3:12
  payers are, quote, continuing to apply their own
• 3:15
  criteria for inpatient admissions
• 3:17
  and dismissing the 2 midnight rule for Medicare
• 3:20
  beneficiaries.
• 3:21
  The firm analyzed claims data for more than
• 3:23
  1900 hospitals between July 2023
• 3:26
  June 2024.
• 3:27
  The analysis compares observation rates prior to and
• 3:31
  following the January 2024 implementation
• 3:34
  of the 2 midnight rule for Medicare Advantage
• 3:36
  plans.
• 3:37
  Kodiak analyzed data for 3 health plan categories,
• 3:40
  commercial, Medicare Advantage, and traditional Medicare.
• 3:43
  The data showed that ma plans began classifying
• 3:46
  fewer observation stays starting in January
• 3:49
  observation rates for ma plans ranged between 18%
• 3:53
  20% of claims in the last 6 months
• 3:55
  of last year and then fluctuated with a
• 3:57
  lower range of 14%
• 3:59
  16%
• 4:00
  in the 6 1st 6 months of this
• 4:01
  year.
• 4:02
  Observation rates in traditional Medicare also trended down
• 4:05
  over the 12 month period but within a
• 4:07
  range of 5.2 to 3.7 percent with the
• 4:10
  exception of a spike to 8 a half
• 4:12
  percent in December.
• 4:14
  According to Kodiak, the gap in observation rates
• 4:16
  between MA plans and traditional Medicare suggest that
• 4:19
  MA plans are not fully complying with the
• 4:21
  federal rule requiring them to offer members the
• 4:24
  same coverage as traditional Medicare. Our data shows
• 4:27
  that MA observation rates are similar to the
• 4:29
  rates among patients covered by commercial insurance. And,
• 4:31
  of course, most of the MA plans are
• 4:33
  also providers of commercial insurance.
• 4:37
  Well, Centene is the latest insurer challenging CMS'
• 4:41
  star ratings in court. In a lawsuit filed
• 4:44
  October 22nd, Centene asked a federal judge to
• 4:46
  require CMS to calculate recalculate its star ratings
• 4:50
  without including a secret shopper phone call. Centene
• 4:53
  says never reached its call centers. C Mass
• 4:56
  conducts secret shopper's
• 4:57
  calls to score plans' customer service functions, including
• 5:00
  text to voice services.
• 5:02
  These services are often used by individuals with
• 5:04
  hearing or speech disabilities.
• 5:06
  In its lawsuit, Centene alleged the agency included
• 5:09
  a call that never reached its call center
• 5:10
  due to no fault of its own Centene
• 5:13
  alleged the secret shopper's notes show that the
• 5:15
  chat window closed unexpectedly
• 5:16
  which Centene called
• 5:18
  a clear failure of CMS's
• 5:20
  software
• 5:22
  star ratings determine whether plans are eligible for
• 5:24
  bonus payments from CMS the inclusion of the
• 5:27
  call in its rating will cause Centene to
• 5:29
  lose out on $73,000,000
• 5:31
  in revenue according to the company
• 5:33
  several other insurers have challenged CMS's star ratings
• 5:36
  in court this year UnitedHealthcare
• 5:38
  also
• 5:39
  disputed the inclusion of a secret shopper phone
• 5:41
  call it says never connected to its call
• 5:43
  center
• 5:44
  well UnitedHealth Group has reached a settlement with
• 5:47
  the US Department of Labor over allegations that
• 5:50
  the company improperly denied claims for emergency room
• 5:53
  visits and urinary drug screenings for thousands of
• 5:56
  patients.
• 5:57
  The final settlement amount is unclear, but that
• 5:59
  order was signed October 21st in a Wisconsin
• 6:02
  federal court. The Labor Department originally filed its
• 6:05
  lawsuit against UnitedHealth
• 6:07
  subsidiary,
• 6:08
  UMR, in July 2023.
• 6:11
  UMR is UnitedHealthcare's
• 6:12
  third party administrator that provides health benefits services
• 6:15
  to more than 21100
• 6:17
  self funded employer plans.
• 6:19
  By denying emergency claims quote based solely on
• 6:22
  diagnosis codes and not implying a prudent layperson
• 6:24
  standard, the government said that UMR violated
• 6:28
  e ERISA
• 6:29
  which oversees
• 6:31
  self funded plans. The department added that UMR's
• 6:35
  explanation to members for the denied emergency claims
• 6:37
  violated the ACA and the government's internal claims
• 6:40
  procedures regulations.
• 6:42
  For urinary test denials, the labor department alleged
• 6:45
  that UMR denied all claims from August 20
• 6:47
  15 to August 2018
• 6:49
  without determining whether a claim was medically necessary.
• 6:53
  The lawsuit had sought to require UMR to
• 6:55
  reform its emergency and urinary drug testing claims
• 6:58
  procedures
• 6:59
  to comply with ERISA and re adjudicate all
• 7:01
  denied or partially denied claims from January 1,
• 7:05
  2015
• 7:06
  to the present day.
• 7:10
  Wall Street analysts say that a potential Cigna
• 7:12
  Humana merger depends on the results of the
• 7:14
  presidential election.
• 7:16
  Bloomberg reported on October 18th that Cigna and
• 7:19
  Humana had resumed merger discussions.
• 7:21
  They were in talks to merge in late
• 7:23
  2023, but the deal fell apart over a
• 7:25
  disagreement on price.
• 7:29
  One analyst with wrote said told Bloomberg that
• 7:32
  the merger would only tangibly move forward if
• 7:34
  Republican nominee Donald Trump wins in November. If
• 7:37
  Humana and Cigna merge, it would create one
• 7:39
  of the largest health care companies in the
• 7:41
  US
• 7:42
  and certainly draw antitrust to scrutiny.
• 7:45
  Under current FTC chair, Lena Khan's leadership, at
• 7:48
  least 7 major health care deals have been
• 7:50
  blocked.
• 7:51
  A second Trump administration could take a more
• 7:53
  permissive view towards m and a. The administration
• 7:57
  approved CVS Health's $69,000,000,000
• 7:59
  acquisition of Aetna in 2018.
• 8:02
  And finally, Elevance Health is laying off a
• 8:04
  123 employees in Southern California.
• 8:07
  Elevance will lay off 59 employees at Anthem
• 8:10
  Blue Cross in Woodland Hills and 64 employees
• 8:13
  at a Carillon office in in Cerritos.
• 8:16
  Last October, CEO Gail Boudreaux said the company
• 8:19
  took about $700,000,000
• 8:20
  in charges due to workforce adjustments and technology
• 8:23
  asset write offs during a strategic review. Since
• 8:26
  then, the company has laid off 90 employees
• 8:28
  at a facility in Dearborn, Michigan, 87 other
• 8:31
  employees in Woodland Hills, and 57 workers at
• 8:34
  a facility in Minnesota.
• 8:36
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• 8:37
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• 8:40
  subscribe to the Becker's payer issues e newsletter
• 8:42
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