The company allegedly submitted fraudulent Medicaid reimbursements while violating licensing and supervision of staff regulations.
Molina Healthcare and its previously owned subsidiary, Pathways of Massachusetts, have agreed to a $4.6 million settlement for allegedly violating the False Claims Act by submitting fraudulent claims for Medicaid reimbursement.
The Long Beach, California-based managed care organization owned and operated Pathways, a group of mental health centers located in Massachusetts, between November 2015 and March 2018, during which time both companies improperly submitted claims for reimbursement to MassHealth, the state's Medicaid program.
Four former Pathways employees filed a civil action lawsuit in the U.S. District Court for the District of Massachusetts, while the attorney general's Medicaid fraud division pursued an investigation into Pathways after a referral from MassHealth.
The whistleblowers, or realtors, alleged in their suit that because Pathways' clinics lacked adequate staffing, they did not qualify as eligible mental health centers.
In their investigation, the attorney general's office "found that Pathways failed to meet the regulatory requirements for frequency and adequacy of supervision, the qualifications of its supervisors, and that Pathways billed for psychotherapy services rendered by unlicensed individuals who were not supervised by appropriately licensed professionals."
"This company routinely allowed unlicensed and unsupervised mental health professionals to provide care to patients, all while billing MassHealth for it," attorney general Maura Healey said in a statement. "MassHealth patients deserve to receive treatment from qualified individuals, and my office will continue to hold providers accountable for violating these fundamental MassHealth requirements."
Molina and Pathways agreed to pay the U.S. and the Commonwealth $4.625 million, plus interest at an annual rate of 1.25%. The realtors will be paid their share of $810,000 plus interest from the U.S. and the Commonwealth.
Pathways ceased operations in March 2018 before Molina selling the subsidiary to a private investment firm in October 2018.
The state becomes the first in the nation to have its request granted for section 1332 waivers to create the Colorado Option.
Colorado becomes the first state to gain approval for its public option Affordable Care Act plan, the Department of Health and Human Services (HHS) announced today.
HHS and CMS granted a section 1332 state innovation waiver for the Colorado Option, a state-specific health coverage plan that will strive to make insurance more affordable and accessible for residents starting in 2023.
"We are thrilled to partner with Colorado in our shared commitment to lowering health care costs and ensuring greater access to quality, affordable care," said HHS secretary Xavier Becerra. "The Colorado Option will help thousands more families sign up for health coverage."
The Colorado Option is expected to lower premiums by an average of approximately $132 per person per month, or 22%. By 2025, plans will lower premiums for all by up to 15%.
Colorado residents can enroll in the plans on the individual market, while small employers with less than 100 employees will also be eligible.
The savings generated by the federal government will be passed on to the state to use for providing subsidies to further increase access to care in the state.
"Through this new model, Colorado leverages federal savings to expand affordability and coverage in the state like no other state has done before," said CMS administrator Chiquita Brooks-LaSure. "The Colorado Option is groundbreaking and a step in the right direction to reduce the uninsured rate, while investing in health insurance coverage affordability and improvements, and advancing health equity. We encourage all states to consider innovative ways to use section 1332 waivers in the future to expand and improve coverage and lower costs for their residents."
The approval for the Colorado Option opens the door for more states to push their public option plan through.
Washington became the first state to offer a public option plan in 2019, but has struggled to gain traction without the cooperation of hospitals and backing of the federal government.
The association responded to annual updates to the inpatient prospective payment system (IPPS).
America's Essential Hospitals (AEH) is calling on CMS to define hospitals that disproportionately serve marginalized patients and implement policies to protect them as part of its comments on the FY 2023 IPPS proposed rule.
As CMS finalizes Medicare inpatient payment policies, AEH wants the governing body to consider how payment cuts will affect the stability of essential hospitals in their effort to promote health equity.
The proposed rule will result in reimbursement cuts in the form of Medicare disproportionate share hospital (DSH) payment reductions, which AEH says will "devastate hospitals facing an uncertain financial future."
By working to define the category of hospitals that disproportionately serve marginalized patients, CMS will ensure essential hospitals are not unfairly disadvantaged and continue to have sufficient resources, especially for future outbreaks of COVID-19.
Once this group of hospitals is defined, AEH are urging CMS to identify new policies that will fund these hospitals, as well as identify current policies that disproportionately harm them, such as ensuring stable Medicare DSH funding.
AEH also wants CMS to adjust its methodology for calculating the annual payment update for FY 2023 to ensure it provides an update that considers inflation and workforce costs on hospitals. CMS' proposal has a net annual payment update of 3.1% caused by a 3.2% market basket update, plus a 0.5% adjustment mandated by legislation, and minus 0.4% productivity adjustment.
Rather, AEH requests a market basket update of at least 5% and the waiving of the productivity adjustment, which can be justified by looking at alternative sources of cost data, such as Medicare cost reports, for a better representation of hospital cost increases.
When it comes to DSH payments, AEH recommends CMS maintain stability for essential hospitals, accurately capture the full range of uncompensated costs hospitals sustain when caring for disadvantaged patients, and ensure transparency in its Medicare DSH methodology.
Other AEH recommendations for CMS include:
Implementing policies that reduce administrative burden on hospitals in the Medicare Promoting Interoperability Program
Continue to refine the hospital Inpatient Quality Reporting Program measure set
Promote the standardized reporting of social risk factors
Provide clear, interpretive guidance on data reporting before the end of the COVID-19 public health emergency
"In working to identify and support essential hospitals, CMS would advance its commitment to health equity, protect the interests of the Medicare program, and preserve access to care for the most disadvantaged Medicare beneficiaries," AEH writes. "We urge CMS to follow these recommendations, and we look forward to working with the agency to advance our shared goals."
The Office of Inspector General (OIG) uncovered that the program and beneficiaries could have saved $1.6 billion combined had they been charged the same payment rate as freestanding facilities.
Medicare and its beneficiaries paid considerably more at provider-based facilities than they would have for the same services at freestanding facilities, according to the OIG.
The OIG's audit examined $3.95 billion paid for evaluation and management (E&M) services at provider-based facilities from 2010 to 2017 in eight states: California, Colorado, Florida, Louisiana, Michigan, Missouri New York, and Texas. Based on outpatient and Physician Fee Schedule (PFS) claims for E&M services performed at provider-based facilities, researchers compared the data to what would have been paid at freestanding facilities.
The cost savings potential was substantial, as Medicare could have saved $1.3 billion, while its members could have saved $334 million, for a combined total of over $1.6 billion.
Instead of Medicare and its beneficiaries paying $1.8 billion and $460 million, respectively, for the freestanding PFS non-facility rate, their actual payments were $3.1 billion and $794 million.
Additionally, beneficiaries would have only had to make one coinsurance payment rather than two and the cost-sharing would have been lower based on the freestanding facility rate.
CMS attempted to equalize payments for E&M services between provider-based facilities and freestanding facilities in the CY 2018 OPPS final rule and CY 2019 PFS final rule, which paid both types of facilities at 40% of what they would have been paid under the OPPS. If the 40% adjuster had been in effect during the period of OIG's audit, the potential cost savings to Medicare and its members would have been a combined $1.4 billion.
OIG undertook the audit because three Medicare Payment Advisory Commission reports to Congress and a previous OIG report found that hospitals were increasingly buying physician practices and operating them as provider-based facilities to receive higher payment rates.
After learning of its findings, OIG "recommended that CMS pursue legislative or regulatory changes to lower costs for both the Medicare program and beneficiaries, by equalizing payments as appropriate between provider-based facilities and freestanding facilities for E&M services."
CMS responded by not directly agreeing or disagreeing with OIG's recommendation, while referring to regulatory action it had taken and adding that further changes "may require legislative action."
Hospitals are facing an additional payment cut to 2% slated for July 1 after a 1% cut took effect in April.
The American Hospital Association (AHA) has written a letter to Congress in the final weeks before additional Medicare sequester cuts are scheduled to go into effect, urging decision makers to provide financial relief as hospitals continue to deal with effects of the pandemic.
After a bill was signed in December 2021 to halt the sequestered cuts, it resumed in April with a 1% cut, which will increase to 2% on July 1 without action from Congress.
In a letter to majority and minority leaders, AHA executive vice president Stacey Hughes expresses concern over the ramifications of the additional cuts, citing expenses for labor, drugs, and supplies, as well as inflation in the economy as significant challenges facing hospitals.
"Hospitals and health systems need financial relief from this pending cut in order to maintain access to care for the patients and communities they serve, while they continue to face dire financial and workforce pressures brought on by the COVID-19 pandemic," Hughes writes.
The letter highlights a poor first quarter of the year financially for hospitals and health systems, as evidenced by operating margins declining 38.1% from March to April.
Hughes also cites how dependent many payments to hospitals and health systems are on Medicare and Medicaid, which are nonnegotiable, fixed reimbursement rates. According to AHA, 94% of hospitals have 50% or more of their inpatient days paid by Medicare or Medicaid, and more than 75% of hospitals have 67% or more Medicare or Medicaid inpatient days.
"Unlike other sectors of the economy, hospitals and health systems cannot deflect these increased costs," Hughes states.
"These fixed costs don’t allow hospitals to absorb or deflect the impact of the historic inflation levels."
After already dealing with the 1% sequester cut that took effect in April, AHA estimates hospitals will lose at least $3 billion by the end of the year if the cut increases to 2% in July.
A survey reveals more than 80% of providers support delaying the requirement until there is a standardized data exchange process.
The convening provider requirements in the No Surprises Act pose challenges for providers, who would rather delay the obligation until data exchange standards are in place, according to a survey by the Workgroup for Electronic Data Interchange (WEDI).
Under the No Surprises Act, a convening provider or facility is responsible for providing a good faith estimate (GFE) to the uninsured patient, which includes contacting all other providers or facilities that may be involved with the patient's service to obtain a GFE for their portion.
However, there is currently no standardized data exchange process between the convening provider and co-providers, with respondents in the WEDI survey saying that absence creates significant burden on providers and facilities.
Over 80% of providers surveyed (83.1%) say they are somewhat or strongly in support of the government delaying the requirement for convening providers/facilities to obtain a GFE from any co-provider/facility until there is a standardized data exchange process in place. Only 7% are somewhat or strongly opposed, while 4.4% are neutral.
"While the No Surprises Act includes much needed consumer protections against catastrophic 'surprise' bills, it also includes challenging data exchange provisions such as the convening provider/facility requirement," stated Charles Stellar, WEDI president and CEO. "Even though the government plans to end enforcement discretion for self-pay patients at the end of this year, currently there is no standard format or established workflow to transmit data to or from the convenor."
The survey was conducted in May and received a total of 273 responses from small providers/clinics (39.6%), large provider clinics (11.5%), health systems (10.4%), medium sized clinics (8.5%), hospitals (2.2%), and other provider types.
Respondents gauge the difficulties of following the convening provider requirements, with 65.8% saying it would be very difficult or difficult for providers and facilities to determine who should be the convening provider. Meanwhile, 11.7% indicate it would be easy or very easy.
An overwhelming 89.3% say it would be very difficult or difficult for the convening provider to identify all appropriate co-providers for the specific medical service, with only 4.8% believing it would be easy or very easy.
An even stronger majority (91.5%) say it would be very difficult or difficult for convening providers to collect GFEs from co-providers for the specific medical service, while just 1.1% indicate it would be easy or very easy.
Finally, 89% state it would be very difficult or difficult for the convening provider to complete the GFE process for a specific medical service and provide it to the patient within the required three business days of being requested or the service being scheduled. Conversely, 2.6% say it would be easy or very easy.
"The survey results suggest providers and facilities will face significant challenges just identifying who the convenor should be, who the appropriate co-providers/facilities should be, and how to collect GFEs from these co-providers/facilities," Stellar said.
"Survey respondents were adamant that meeting the legislation's three-day deadline to get the GFE to the patient would be difficult or very difficult. Not surprising, respondents expressed strong support for the government delaying the convenor requirement until a standardized process to exchange data between convening providers and co-providers/co-facilities is established."
Findings in a recent survey of beneficiaries push back on criticism of the service's administration.
While Medicare Advantage (MA) has come under scrutiny for administration issues, members of the service are overwhelmingly satisfied with their coverage, according to a survey by eHealth.
The licensed broker of Medicare insurance plans surveyed 2,848 MA enrollees in May and found that nearly nine in 10 members (88%) are happy with their plan.
Nearly two thirds (63%) say they are "very satisfied" with their MA plan, while 25% say they are "somewhat satisfied", 7% say they are neither satisfied nor dissatisfied, and 6% express dissatisfaction.
Among those that are dissatisfied with their plan, 29% cite lack of coverage for their preferred doctors, hospitals, or pharmacies. Another 25% cite out-of-pocket costs, while 22% take issue with their prescription drug coverage.
Still, 86% of enrollees would recommend it to family and friends in need of Medicare coverage, with only 3% saying they would not. More than half of members (51%) like their plan because it covers their preferred doctors, hospitals, and pharmacies, while 49% cite affordable monthly premiums, and another 49% say it covers their prescriptions drugs at a price they can afford.
Nearly half of enrollees (46%) say they chose MA because they wanted all their Medicare benefits wrapped up in a single plan.
The survey comes on the heels of a report by the Office of Inspector General (OIG) that found Medicare Advantage organizations (MAOs) often unnecessarily deny prior authorizations.
The OIG reported that 13% of prior authorization denials met Medicare coverage rules and 18% of payment denials met Medicare coverage and MAO billing rules.
The bipartisan legislation, which has gained the support of several provider and patient advocacy groups, as well as Better Medicare Alliance, would reform prior authorization processes for MA plans.
Respondents in the eHealth survey also detail their experience with prior authorization denials, with 13% saying they had a claim or request denied. Only 3% say they were denied coverage for a specific prescription drug, while 2% were denied coverage for visits with specific doctors, and 1% were denied coverage for inpatient hospital care. The survey notes that many of the members that experienced denials were declined for services like dental and vision care, which aren't typically covered by Medicare.
Of those who had a claim or request denied, 43% say they were informed it was excluded from coverage under their plan. An additional 15% say their coverage was denied because the service or supply was determined to be unnecessary. Another 15% say that after their claim or request was initially denied, it was eventually paid by their insurer.
"This expansive survey of more than 2,800 Medicare Advantage enrollees confirms what we already know: Medicare Advantage remains highly popular among the audience that matters most – beneficiaries – despite misleading attacks from outside groups that seek to undercut the care and coverage that more than 28 million Americans rely on," Mary Beth Donahue, president and CEO of the Better Medicare Alliance, said in a statement.
"Further, this survey reaffirms that, overwhelmingly, prior authorization is applied appropriately and selectively as a clinical tool to coordinate care for beneficiaries."
The hospitals, which are part of the same health system, failed to comply with CMS requirements by not making public their list of standard charges for services in a machine-readable file and single digital file.
CMS first issued warnings last year to Northside Hospital Atlanta in April and Northside Hospital Cherokee in May before completing a review of the facilities in September 2021.
The civil monetary penalties were calculated as $300 per day of noncompliance, combined with the size of the hospital based on the number of beds.
The hospitals are required to pay the fines in full within 60 days from the date of the notice or can request an appeal hearing before HHS.
"CMS expects hospitals to comply with the Hospital Price Transparency regulations that require providing clear, accessible pricing information online about the items and services they provide," Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, said in a statement.
"This enforcement action affirms the Biden-Harris Administration's commitment to making health care pricing information accessible to people across the country and we are committed to ensuring that consumers have the information they need to make fully informed decisions regarding their healthcare."
Northside Hospital Atlanta and Northside Hospital Cherokee were only two of hundreds of facilities across the country to receive warning letters from CMS as of early June. A total of 352 warnings have been issued, including 157 cases requiring a request for a corrective action plan and 171 hospitals who addressed their issues to have their case closed.
A recent study by JAMAevaluated by the price transparency rule six to nine months after it took effect, finding that hospitals in rural, more concentrated markets with less competition were less likely to comply.
Of the 5,239 hospitals researched by the study, 51% (2,668) didn't have a machine-readable file or a shoppable display.
Meanwhile, revenue cycle leaders expressed their concern that the price transparency rule is too confusing and expensive to achieve its intended purpose in an April report by KLAS.
Most of the respondents in the report said significant resource investment is necessary to implement and sustain price transparency compliance. However, finding resources can be difficult as organizations weigh the financial burden of investing in a regulation that doesn't provide a return on investment, according to the report.
"Many organizations are not investing beyond the bare minimum requirements, and they don't plan to do more until there is further clarity around the regulations and the expectations going forward," the KLAS authors wrote.
The drop followed the decline in use of healthcare services during the early stages of the COVID-19 pandemic.
For the first time in more than two decades, traditional Medicare spending fell in 2020 in the wake of COVID-19's arrival, according to a Kaiser Family Foundation report.
As healthcare services experienced a significant decline in the early months of the pandemic, the study found that spending among traditional Medicare beneficiaries on Part A and Part B services in decreased 5.8% from 2019 to 2020 ($369.5 billion to $348 billion).
Medicare spending per beneficiary fell 3.6% to $10,739 per person, compared to $11,142 in 2019.
Total Medicare spending increased, however, due to federal payments per Medicare Advantage (MA) enrolee rising 6.9%, according to the analysis, which used data from CMS. MA payments did not reflect the lower utilization of 2020 as they were determined in mid-2019 before the pandemic.
"Understanding how spending and utilization changed across different types of services in 2020 is useful for identifying areas where beneficiaries delayed or skipped care in response to the pandemic, which could have longer-term implications for health outcomes and Medicare spending," the authors of the study stated.
Only three types of Medicare services saw increases in usage in 2020: hospice, dialysis, and Part B drugs. The increase was by less than one percentage point though.
Meanwhile, the largest drops in usage were for imaging services, which fell 5.5%, followed by outpatient hospital services, which declined 4.8%.
Spending for most services decreased, ranging from 0.1% less for durable medical equipment to 13.1% less for procedures. Only spending on skilled nursing facilities, Part B drugs, and hospice increased from 2019.
It's unclear to what extent the decrease in usage affected Medicare beneficiaries, but the authors write that "it is possible that the decline in use could have negative implications for future health if people delayed routine care and screenings or were unable to schedule procedures in a timely manner, missing the opportunity for early diagnosis and treatment.
"The drop in utilization also has the potential to lead to higher future health care spending if more health care services are required or if treatments are more intensive."
While 2020 marked the first time Medicare spending declined since 1999, the study attributes the aberration to the pandemic and projects spending to rebound and continue growing.
The authors conclude: "There is a question of whether any of the changes in spending and use will be sustained, though the expectation is that these were most likely one-time, or otherwise short-lived, changes."
A survey from AHIP and the Blue Cross Blue Shield Association (BCBSA) finds that the law protected millions of patients immediately after going into effect.
In its first two months as a law, the No Surprises Act protected patients from more than two million surprises bills, according to a survey from AHIP and BCBSA.
After being signed into law in December 2020, the No Surprises Act went into effect on January 1, 2022, with the purpose of ending surprise medical bills for out-of-network services.
"The No Surprises Act ended the practice of surprise medical billing in most circumstances, providing relief for millions of patients who faced surprise medical bills they did not expect at prices they could not afford," said Matt Eyles, AHIP president and CEO. "Health insurance providers applaud the Administration and Congress for taking this important step. But more work needs to be done to ensure a broken bone doesn't break the bank."
The survey conducted by AHIP and BCBSA examined the number of claims that were eligible for dispute under the No Surprises Act in the first two months of 2022. Of the 83 commercial health plans surveyed, 31 plans—representing 54% of the total commercial market—responded.
Eligible claims included emergency services by an out-of-network provider and non-emergency services by an out-of-network provider at an in-network facility.
The research found 600,000 claims, or 0.23% of the plans' responses, eligible for protection under the No Surprises Act.
Taking into account delays in claims processing, the researchers then calculated the share of eligible claims per enrollee before multiplying that number by the 2020 Census estimate of the total number of commercial enrollees (213 million).
The result was the final estimate of more than two million surprises bills avoided across all commercially insured patients, which would project to over 12 million surprises bills prevented for all of 2022.
AHIP and BCBSA note that even if only a fraction of these claims are ultimately disputed through the independent dispute resolution process, it would still greatly exceed the estimate of 17,000 annual claims by the government.
"There is no room for surprise medical bills in a health care system that puts people first," said Kim Keck, BCBSA president and CEO. "As recently as last year, an emergency visit to the hospital may have left patients on the hook for steep, surprise medical bills. The No Surprises Act has not only put an end to this loophole, but it has provided undeniable financial protection to millions of Americans."
