Federal regulators are ramping up scrutiny of health system contracting practices, escalating the debate over healthcare costs, competition and market power. The Justice Department recently filed antitrust lawsuits against major health systems, including OhioHealth and NewYork-Presbyterian, alleging they used payer…
Author: Alan Condon
Justice Department sues OhioHealth for allegedly blocking lower-cost health plans — 4 things to know
The Justice Department and the state of Ohio on Feb. 20 filed a civil antitrust lawsuit against OhioHealth, alleging the system used anticompetitive contract provisions to drive up healthcare costs for patients and employers in central Ohio. Four things to…
Medicare Advantage now covers about 55% of eligible beneficiaries nationwide — more than 35 million people — but health systems are confronting a question that until recently felt almost taboo: What happens when participation in the country’s fastest-growing Medicare program…
When San Diego-based Scripps Health walked away from nearly all of its commercial Medicare Advantage contracts Jan. 1, 2024, the move drew widespread attention across the industry. Medicare Advantage enrollment was still climbing nationally and many health systems were doubling…
As more hospitals and health systems grow frustrated with Medicare Advantage plans, Ascension is among the organizations rethinking how — and whether — to continue participating. Delays in care, high denial rates and growing administrative burdens are prompting tougher contract…
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Medicare Advantage has long been viewed as a strong alternative to traditional Medicare, but the program has “deteriorated significantly” in recent years — benefitting commercial payers at the expense of patients and providers, according to Providence President and CEO Erik…
Oakland, Calif.-based Kaiser Permanente has agreed to pay $556 million to resolve allegations that it violated the False Claims Act by submitting invalid diagnosis codes for Medicare Advantage enrollees to obtain higher payments from the federal government. According to the…
Health plans were early adopters of AI, using it to streamline claims processing, support call centers and manage utilization. Now, they’re ramping up AI deployment to enhance member experience, improve care quality and reduce administrative costs, according to America’s Health…
Major payers reported mixed third-quarter results amid rising medical costs and operational headwinds, a stark contrast to the more robust performance seen by some of the largest for-profit health systems. Becker’s compared Q3 performance across six major payers — UnitedHealth…
CMS is set to launch a pricing model in January that could reshape Medicaid drug costs by aligning them with rates seen in other high-income countries. Eight things to know: 1. The program allows participating drug manufacturers to offer Medicaid…