Medicare Advantage

Elevance Health sued the U.S. government, claiming federal recalculation of its Medicare Advantage quality ratings violated a recent court ruling, resulting in a $115 million loss. The lawsuit, filed in Georgia, challenges the impact of revised star ratings on the insurer's eligibility for bonuses and rebates tied to quality thresholds.

Medicare is a federal health insurance program for those aged 65 and older, as well as individuals under 65 with disabilities or conditions like end-stage renal disease or ALS. It includes parts A, B, and D for hospital, outpatient, and prescription drug coverage, with costs varying annually. Medicare Advantage (Part C) offers an alternative through private plans, often with network restrictions.

Margaret Hvatum, a 70-year-old with primary immunodeficiency, faced insurance denials for her lifesaving drug Hizentra after switching Medicare Advantage plans, leading to health complications and denied hospital charges. The denial stemmed from prior authorization issues, a process that contributed to her hospitalization and financial burden.

Federal officials recalculated the 2026 Medicare Advantage star ratings due to legal challenges from health insurance companies over lower ratings affecting bonus payments. The bonuses for plans with at least four stars have reached $16 billion this year, doubling since 2020.

The article outlines seven key questions to consider during Medicare Open Enrollment to avoid unexpected costs and penalties. It emphasizes evaluating plan networks, provider availability, and differences between original Medicare and Medicare Advantage plans, including provider types like participating, nonparticipating, and opt-out physicians.

Original Medicare (Parts A and B) does not cover hearing aids or routine hearing exams, but Medicare Advantage plans may offer coverage for hearing aids and related services. Hearing aid costs range from $100 to over $7,000, with OTC options averaging $930 and prescription devices averaging $3,300. Medicare Part B covers medically necessary diagnostic hearing tests ordered by a doctor.

Casey Ross and Bob Herman report that large Medicare Advantage insurers used artificial intelligence to override clinicians' judgments, denying care to seriously ill older and disabled patients. The article highlights a suspicious pattern of denied care in Medicare Advantage plans.

Federal investigators found that dominant Medicare Advantage insurers, including UnitedHealth Group and Humana, denied rehabilitative care for older and disabled Americans at higher rates than peers, with 97% of denials overturned upon patient appeal. These insurers used a UnitedHealth subsidiary, NaviHealth, which employs AI to assess care needs, but frequently reversed its denials after scrutiny during appeals.

Matrix Medical Network, HealthFair, and founder Shahriah 'James' Ekbatani agreed to pay $56.5 million to resolve allegations of violating the False Claims Act by submitting false diagnosis codes to Medicare Advantage. Matrix will pay $36.5 million, HealthFair $5 million, and Ekbatani $15 million as part of separate qui tam actions in New York and Texas.

Community Care Health Network (Matrix), HealthFair, and founder Shahriah 'James' Ekbatani agreed to pay $56.5 million to resolve allegations of violating the False Claims Act by submitting false or invalid diagnosis codes to Medicare Advantage. Matrix will pay $36.5 million, HealthFair $5 million, and Ekbatani $15 million as part of separate qui tam actions in New York and Texas.

Massachusetts Attorney General Andrea Joy Campbell is suing UnitedHealthcare, a subsidiary of UnitedHealth Group, for allegedly inflating diagnoses of low-income seniors in the state’s Medicaid program to secure at least $100 million in fraudulent payments. The lawsuit claims the company used deceptive upcoding practices over the past decade, marking one of the first such cases targeting dual eligibles enrolled in both Medicare and Medicaid.

Blue Cross Blue Shield of Michigan and Michigan Medicine announced a long-term contract agreement, ensuring continued in-network healthcare access at University of Michigan facilities beyond the current June 30 deadline. The deal resolves a months-long dispute over reimbursement rates and contract terms, with financial details to be finalized. Both parties emphasized maintaining patient access to care while addressing affordability.

A federal judge ruled that Peter Haytaian, a former top executive at Elevance Health, must testify under oath in a Department of Justice fraud case involving Medicare Advantage plans. Elevance had blocked the deposition, claiming Haytaian lacked relevant knowledge despite overseeing government health plans for over four years during the alleged overbilling period. The ruling represents a significant victory for the DOJ in a six-year-old case.

Medicare Advantage brokers earn $10 billion annually in commissions, raising questions about their role in helping clients. The commissions are paid for enrolling and retaining individuals in Medicare Advantage plans. This practice has sparked concerns over the brokers' motivations.

Dr. Mehmet Oz announces a health coalition to simplify prior authorization for medical treatments, streamlining the process with 29 major healthcare players. The coalition includes insurers, hospitals, and health records companies. This move aims to reduce administrative headaches for doctors and improve patient care.