Payer

Medicare Advantage plans received $50 billion in payments between 2018 and 2021 for "questionable diagnoses" insurers added to medical records, a Wall Street Journal investigation published July 8 has found. 

Payers have faced state penalties over the last year for slow reimbursements, improper claims denials, or the sale of unapproved products.

Here are five updates on prior authorization, Becker's has reported since June 18:

Forty organizations received revised star ratings from CMS after the agency recalculated its star ratings for 2024. 

HHS' Office of Inspector General will audit Medicare Advantage plans' use of prior authorization in post-acute care settings. 

A group of 24 lawmakers expressed concern Express Scripts could be limiting Tricare beneficiaries' choice of pharmacies. 

Texas has fined Cigna $600,000 for failing to comply with multiple independent claims dispute resolution requirements under state law. 

 In 2023, gross margins per member were highest in the Medicare Advantage market, and medical loss ratios were lowest in the individual market, according to a July 2 analysis from KFF.

The Massachusetts Department of Public Health has launched an initiative that redirects patients not needing emergency-level care to urgent care providers to address "severe capacity challenges" at hospital emergency departments in the eastern part of the state.

Seven additional Medicare Advantage contracts picked up five-star ratings from CMS after the agency recalculated its ratings for 2024.