Feds drop bomb on Multiplan in legal war over healthcare ‘price-fixing’ algorithms

The US Justice Department on Thursday weighed into an antitrust legal war that alleges algorithmic price fixing by healthcare services by MultiPlan and its health insurance clients.

Ninth Circuit Revives Class Action Suit Against UnitedHealth for Alleged Violations of the Mental Health Parity and Addiction Equity Act

In Ryan S. v. UnitedHealth Group Inc., 2024 U.S. App. LEXIS 8729, the Ninth Circuit Court overturned a lower court decision and found that UnitedHealth Group (UHG) must face a class action suit alleging it violated the Mental Health Parity and Addiction Equity Act.

Drug, substance abuse and addiction statistics 2024

Drug and substance abuse continues to be a major problem across the United States, with 1 in 4 Americans over the age of 12 admitting that they used illicit drugs in 2022.

Aetna Sues California Addiction Treatment Providers for Exploiting Patients and Insurance Fraud

A Closer Look at Fraud and Abuse in the Addiction Treatment Industry in Orange, Los Angeles, and Riverside Counties

Aetna clarifies updated telehealth policy does not apply to fully insured enrollees

Aetna recently announced it was excluding fully insured commercial plans in all 50 states from its new telehealth policy that took effect December 1, 2023, eliminating coverage for audio-only and asynchronous telehealth services.

UnitedHealth, Cigna face lawsuits over alleged automated claims denials

UnitedHealthcare and Cigna Healthcare are facing lawsuits from members or their families alleging the organizations use automated data tools to wrongfully deny members’ medical claims.

Owner of Southern California sober living homes sentenced to 2 years for fraud

Bakersfield attorney admits to scheme that turned urine to gold after overbilling insurance firms for medical tests

Insurers slam mental health parity plan

The Biden administration has proposed expanding requirements for insurers to cover mental health and substance use treatment as they do for other care — and insurers aren’t happy.

Cigna faces second class-action suit over automated claims denials

Insurance giant Cigna is facing a second class-action lawsuit pertaining to its utilization of claims automation software.

Cigna using AI to reject claims, lawsuit charges

igna, one of the country’s largest health insurance companies, faces a class action lawsuit over charges that it illegally used an artificial intelligence (AI) algorithm to deny hundreds of thousands of claims without a physician’s review.

Cigna Health Giant Accused of Improper Violation of California Law

A federal lawsuit alleges that health insurance giant Cigna used a computer algorithm to automatically reject hundreds of thousands of patient claims without examining them individually as required by California law.

UnitedHealth, Nation’s Biggest Health Insurer, Reports Record Use Of Behavioral Care Services

As the U.S. mental health crisis deepens, the nation’s largest health insurer is seeing record use of behavioral healthcare services across all age groups. UnitedHealth Group, which reported second quarter earnings on Friday, told analysts who follow the company that its giant network of behavioral care providers from psychiatrists and psychologists to therapists and social workers and specialized nurses is expanding to meet demand.

UnitedHealthcare vs. Aetna vs. Centene: 10 key comparisons to know in 2023

UnitedHealthcare, Aetna and Centene are three of the largest healthcare payers in the U.S. This article shows how the organizations stack up across 10 areas.

SB-858 Health care service plans: discipline: civil penalties.

This bill proposes an amendment to the existing law, the Knox-Keene Health Care Service Plan Act of 1975 which regulates the licensure and regulation of health care service plans by the Department of Managed Health Care. The bill increases the base amount of the civil penalty for violation of the act from $2,500 to $25,000 per violation, authorizes a lower penalty for specialized dental and vision health care service plans and also authorizes the Director of the Department of Managed Health Care to impose a corrective action plan to require future compliance with the act. It also adjust the penalties annually, doubles the minimum and maximum amounts of the civil and administrative penalties and makes the failure to comply with a corrective action plan as grounds for disciplinary action. The bill also requires the Director to determine the appropriate amount of the penalty for each violation based on certain factors such as the nature and scope of the violation and whether it’s an isolated incident.

Elevance Health to Acquire Blue Cross and Blue Shield of Louisiana

Elevance Health (formally Anthem) and Blue Cross and Blue Shield of Louisiana have entered into an agreement in which Elevance Health will acquire Blue Cross and Blue Shield of Louisiana (BCBSLA). The acquisition will unite the two organizations in their mission to improve whole health and improve access, quality, affordability, and the experience of healthcare for the people of Louisiana. With the acquisition, BCBSLA will join Elevance Health’s affiliated Anthem Blue Cross Blue Shield family of brands, and the Louisiana plan headquarters will remain in Baton Rouge.

For addiction treatment, longer is better. But insurance companies usually cut it short

Access to treatment for addiction has long been a problem for U.S. health systems due to the cost and the lack of long-term value placed on addiction treatment by insurance companies and other payers. As a result, access to treatments that work are available only to those who can afford them, while millions of Americans receive substandard treatment or none at all. Decades of research show that longer treatment is the number one predictor of addiction treatment outcomes, but insurance companies often approve only the minimum number of treatment days to reduce upfront costs. To improve access to addiction treatment, payers and providers need to improve their ability to measure and monitor extended treatment on outcomes and relapse costs and invest in technology systems and processes that connect treatment to outcomes.

California Plans Deny Mental Health Claims Despite New Law

More than two years after California passed a law to require more comprehensive mental health coverage, health insurance companies still appear to regularly deny claims for medically necessary treatment, a survey of state data shows.

 

The Failed Promise of Online Mental-Health Treatment

Heavy advertising and other strategies from Silicon Valley’s playbook boost providers’ growth but not the quality of care. Remote treatment of mental-health problems surged in the pandemic, as in-person treatment became difficult while pandemic-driven isolation increased anxiety and depression.

 

HHS Proposes New Protections to Increase Care Coordination and Confidentiality for Patients With Substance Use Challenges

Today, the U.S. Health and Human Services Department, through the Office for Civil Rights (OCR) and the Substance Abuse and Mental Health Services Administration (SAMHSA), announced proposed changes to the Confidentiality of Substance Use Disorder (SUD) Patient Records under 42 CFR part 2 (“Part 2”), which protects patient privacy and records concerning treatment related to substance use challenges from unauthorized disclosures.

 

Self-funded plans sue Anthem, alleging overcharging and other ERISA violations

Employers claim that the health care company, now known as Elevance Health, breached its fiduciary duties under ERISA because they were denied access to plan claims due to mismanagement of funds.

 

What Will UnitedHealth’s New Trove of Claims Data Mean for Consumers?

A federal judge allowed the company to acquire a clearinghouse of health insurance claims. UnitedHealth says it won’t use the data to give itself an edge, even as some company documents suggest otherwise.

 

What employers must know about mental health parity

The COVID-19 pandemic exacerbated what was already a severe mental health crisis in America, leading to a serious shortage of therapists and rising substance abuse rates. To get the care they urgently need, many patients and families are forced to take on unprecedented amounts of debt — often without knowing that their insurers or their group health plans are supposed to foot the bill.

 

Centene Showers Politicians With Millions as It Courts Contracts and Settles Overbilling Allegations

On Nov. 2, 2021, Nevada Gov. Steve Sisolak’s reelection campaign received 10 separate $10,000 contributions from what appeared to be unrelated health insurance plans from across the country.

California Providers Can’t Keep Up With Mental Health Parity Law

California health insurers are having trouble complying with a new state law intended to protect people from paying high out-of-pocket expenses for psychological or addiction care.

 

Longest Strike Ends: California Mental Health Care Workers Win Big

Two thousand mental health clinicians have won; Kaiser Permanente has lost. The 10- week strike has ended in near total victory for the National Union of Healthcare Workers (NUHW). The therapists, walked out on August 15; it became the longest mental health care workers’ strike recorded.

 

Pritzker Administration Announces a $1.25 million fine for Celtic Insurance Company for Violation of the Mental Health Parity and Addiction Equity Act and the Network Adequacy and Transparency Act

CHICAGO – The Illinois Department of Insurance (IDOI) announced today a $1.25 million fine for Celtic Insurance Company, a subsidiary of Centene Corporation, for violating the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Network Adequacy and Transparency Act (NATA), as revealed in the Department’s comprehensive market conduct examination of the company.

 

States need help to enforce mental health parity laws, report finds

State insurance departments are at the front line in enforcing federal mental health protections for plan enrollees but have limited resources to do so.

 

Justice Department sues Cigna for allegedly exaggerating conditions of Medicare Advantage members

The Department of Justice filed a new lawsuit against Cigna Monday, alleging the health insurance company overcharged the federal government by purposefully inflating how sick its Medicare Advantage members were.

 

US health insurance prices went up nearly 30% over the past year

Health insurance prices reported their highest yearly annual increase since the US Bureau of Labor Statistics (BLS) began posting them in 2005.

 

Blue Shield of California sues state over Medi-Cal changes

Blue Shield of California has filed a lawsuit against the state’s Department of Health Care Services alleging the department of failing to supply documents detailing plans for how it will contract with for-profit insurers who seek participation in Medi-Cal, California’s Medicaid program.

 

A Law Designed To Protect Health Consumers Has Ended Up Hurting Them

Vernon Price was excited. He needed to find a new mental health care provider who accepted his Medi-Cal insurance plan. As a mental health advocate in Humboldt County, he’d heard the horror stories — patients who called 20 providers only to find they didn’t exist, didn’t accept insurance, or didn’t have openings.

 

Federal Court Gives Green Light to Deny Coverage

Nearly every psychiatric clinician I know has experienced it: Their patient’s health plan determines—with little justification—that the needed treatment is “not medically necessary.” The clinician is then forced to spend valuable time fighting for coverage of the treatment that is validated by accepted clinical standards of care.

 

House Passes Behavioral Health Parity Bill That Could Penalize Insurers

Insurers that are not compliant with behavioral health parity rules could soon face new penalties. Yesterday The U.S House of Representatives passed a new mental health act, that would impose fines on health plans that do not meet parity regulations and make it easier to sue insurers over behavioral health denial claims.

 

Patients, doctors sue to hold Cigna accountable for underpayments

In an effort to shed light on misconduct by one of the nation’s largest health insurance plans, patients and physicians have filed a proposed class-action lawsuit (PDF) alleging the company intentionally underpaid patients’ medical claims.

 

Payers oppose House mental health parity bill that introduces new insurer fines

A key payer group is calling for lawmakers to oppose House legislation that levies hefty fines on insurers if they don’t follow mental health pay parity requirements, even as a congressional scorekeeper estimates very few insurers will face the penalties.

 

Wyden calls for insurers to face consequences for running ‘ghost’ provider networks

Sen. Ron Wyden, D-Oregon, called for insurers to face consequences when they run a “ghost network,” where providers are listed as part of the network but don’t offer care.

 

In a blow to DOJ, judge allows UnitedHealth-Change Healthcare merger to move forward

A federal judge will allow UnitedHealth Group’s acquisition of Change Healthcare to proceed, dealing a blow to the Biden administration’s healthcare antitrust efforts.

Push for mental health parity hits turbulence

Senators eager to address mental health care this year are encountering stiff headwinds in a bid to ensure parity, the idea that health insurers cover behavioral health and substance abuse at the same level as physical health.

 

AMA, Other Medical Groups Go After CIGNA over Underpayments – RevCycleIntelligence

The groups joined a class action lawsuit against Cigna, claiming that the private payer reimbursed providers in the MultiPlan network at lower rates than previously agreed upon.

 

Kaiser Mental Health Workers Allege State Law Violation

Mental health therapists and nurses at Kaiser Permanente in their fifth week of striking for improved working conditions have called on state regulators to prevent the health care provider from using temporary replacement workers which they claim could postpone patient care during the strike.

 

A Cautionary Tale

Nick Carusillo died when he was hit by multiple vehicles on a Georgia interstate, just days after he was abruptly discharged from an addiction treatment center. Now his parents hope a substantial jury verdict in their favor will prompt change that helps others suffering from mental illness and substance abuse.

 

Inpatient vs. Outpatient Rehab: Which Is More Effective?

Even before the coronavirus pandemic occurred, the number of people in the U.S. age 18 and older with at least one substance use disorder (SUD) was estimated to be over 20 million.  Since the dawn of the pandemic, researchers have noted increases in substance use disorders and drug overdoses. With those statistics in mind, the need for rehab is more important than ever today. However, not all rehab approaches are the same. Here’s how inpatient and outpatient compare with each other.

 

California health care union calls for $25 per hour minimum wage

The union has pushed for ordinances in California cities establishing a minimum hourly wage of the same amount for workers at private healthcare facilities. It said that raising the minimum wage would help address workforce challenges.

 

California probes Kaiser over enrollee access to mental health appointments

The California Department of Managed Health Care has launched a targeted enforcement investigation into whether Kaiser Permanente health plans are providing patients with timely access to appointments, as required by law, during a strike by mental health clinicians at the system’s facilities, a DMHC spokeswoman confirmed in an email to Healthcare Dive on Sunday.

 

Kaiser faces state probe over mental health access amid strike

The California Department of Managed Health Care has opened a targeted enforcement investigation to examine whether Oakland, Calif.-based Kaiser Permanente is providing timely access to appointments during an ongoing strike by mental healthcare workers

 

Study: Costs to add substance abuse coverage to Medicare to only increase spending by nominal amount

The study, released Wednesday (PDF) by the Legal Action Center, comes as Congress is eyeing legislation to expand access to coverage for mental health and substance abuse disorders. Researchers found that any increase in costs to Medicare would be offset by lower costs for related healthcare conditions.

 

Q&A with Aetna’s Chief Medical Officer Dr. Kyu Rhee on creating a ‘values-based system’

Kyu Rhee, MD, is a senior vice president at CVS Health and chief medical officer at Aetna. He sat down with Becker’s to discuss ongoing trends across the healthcare industry and how he is working to create a “values-based” care system through opportunities offered by a global pandemic.

 

Cigna’s Evernorth, Kaiser Permanente ink 5-year network agreement

Cigna’s Evernorth and Kaiser Permanente have inked a multi-year network agreement that aims to drive greater convenience and affordability.

 

Shareholders approve CVS-Aetna acquisition

Shareholders at both CVS Health and Aetna voted Tuesday to approve the drugstore chain’s acquisition of the health insurer, a deal valued at $69 billion.

 

Major insurers running billions of dollars behind on payments to hospitals and doctors

Anthem Blue Cross, the country’s second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.

 

Essential Reading: Murphy, Blumenthal, Colleagues Reintroduce the Behavioral Health Coverage Transparency Act

WASHINGTON—U.S. Senators Chris Murphy (D-Conn.), a member of the U.S. Senate Health, Education, Labor, and Pensions Committee, and Richard Blumenthal (D-Conn.) joined 12 of their Senate colleagues in reintroducing the Behavioral Health Coverage Transparency Act, legislation that would strengthen oversight and enforcement of federal parity laws.

 

Essential Reading: No Surprises Act Implementation: What to Expect in 2022

The No Surprises Act (NSA) establishes new federal protections against surprise medical bills that take effect in 2022. Surprise medical bills arise when insured consumers inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose.

 

CareFirst unveils new virtual primary care practice, CloseKnit

Blues insurer CareFirst is launching a new virtual primary care practice called CloseKnit.

Major payers including Aetna, UHC sign on to California primary care initiative

Six organizations in the state have signed a memorandum of understanding, agreeing to invest in boosting access to advanced primary care, a model that emphasizes whole-person care for high-quality outcomes.

Battle lines are drawn over California deal with Kaiser Permanente

California counties, health insurance plans, community clinics, and a major national health care labor union are lining up against a controversial deal to grant HMO giant Kaiser Permanente a no-bid statewide Medicaid contract as the bill heads for its first legislative hearing Tuesday.

 

Payers Suit alleges Blue Shield improperly denied mental health, drug treatment claims

Blue Shield of California and its claims administrator wrongly restricted patients’ access to outpatient and residential mental health treatment, a class-action lawsuit says.

Hospitals launch campaign to repeal L.A.’s new healthcare minimum wage

A coalition of Los Angeles hospitals and other health facilities launched a campaign on Tuesday to repeal a newly enacted ordinance boosting the minimum wage for thousands of healthcare workers to $25 per hour, saying the law will have a harmful effect on medical care across the city.

 

AHIP and BCBSA analysis finds new law prevented more than 2M surprise medical bills

More than 2 million potential surprise medical bills across all patients in commercial plans were prevented in the first two months a key law went into effect, a new study said.

Insurance groups AHIP and the Blue Cross Blue Shield Association released a survey and analysis (PDF) of the impact of the No Surprises Act, which banned surprise medical bills starting this year. The analysis comes as providers and the Biden administration continue to battle in court over how to handle disputes over surprise bills.

 

How much health insurers pay for almost everything is about to go public

Consumers, employers, and just about everyone else interested in healthcare prices will soon get an unprecedented look at what insurers pay for care, perhaps helping answer a question that has long dogged those who buy insurance: Are we getting the best deal we can?

 

Senator Wiener’s Health Plan Accountability Act, SB 858, Passes Assembly Health Committee

SACRAMENTO – Today, Senator Scott Wiener’s (D-San Francisco) legislation to improve health plan accountability, Senate Bill 858, passed the Assembly Health Committee by a vote of 11-2. SB 858 will now head to the Assembly Appropriations Committee.

 

Sober Home Owner Sentenced to 30 Months in Prison for $4.5 Million Kickback Scheme

A Florida woman was sentenced today to 30 months in prison for a scheme to solicit and receive illegal kickbacks and bribes in exchange for referring residents of her sober home to a substance abuse treatment center.

 

Ninth Circuit Reverses Decision Requiring Reprocessing of 67,000 Behavioral Health Claims; Hands United Healthcare a Win

The Ninth Circuit Court of Appeals recently reversed the Northern District of California’s landmark decision against UnitedHealth Group Inc.’s behavioral health unit, United Behavioral Health (“UBH”), under which UBH had been ordered to reprocess tens of thousands of behavioral health claims.

 

United Healthcare and Anthem Sued for Coverage Denial on Residential Treatment Claims

Two separate suits were filed in the District of Utah on Tuesday. The first health insurance suit was filed against defendants Anthem Blue Cross Life and Health Insurance Company and the Snap Inc.

 

2022 MHPAEA Report to Congress

Realizing Parity, Reducing Stigma, and Raising Awareness: Increasing Access to Mental Health and Substance Use Disorder Coverage

 

Senators Hassan, Murkowski, Luján Introduce Bipartisan Bill to Increase Investments in Substance Misuse Prevention, Treatment, and Recovery

U.S. Senators Maggie Hassan (D-NH), Lisa Murkowski (R-AK), and Ben Ray Luján (D-NM) introduced bipartisan legislation to increase investments in substance misuse prevention, treatment, and recovery programs. The Substance Use Prevention, Treatment, and Recovery Act reauthorizes and strengthens the Substance Abuse Block Grant program, including by requiring that funding goes to evidence-based services, including medication-assisted treatment.

 

Governor Newsom’s CARE Court Proposal Moves Forward

SACRAMENTO – On the heels of California awarding over half a billion dollars for housing and services serving people experiencing mental health and substance use crises, Governor Gavin Newsom’s CARE Court proposal today cleared a major legislative hurdle.

 

‘Untreated’: Patients with opioid addiction could soon lose access to virtual care

Federal regulations that have allowed practitioners the flexibility to prescribe buprenorphine virtually — and to patients outside their state — are due to expire along with the Covid-19 public health emergency.

 

Alcohol and Cannabis are Top Reasons People Seek Substance Misuse Treatment

A new report finds that alcohol and cannabis are the most common reasons people pursue substance misuse treatment.

 

Addiction Treatment Facility Operators Sentenced in $112 Million Addiction Treatment Fraud Scheme

Two brothers who operated multiple South Florida addiction treatment facilities were sentenced to prison Friday for a $112 million addiction treatment fraud scheme that included paying kickbacks to patients through patient recruiters and receiving kickbacks from testing laboratories.

 

How segregated payments keep comprehensive substance use disorder care out of reach

Despite an overall drop in opioid prescribing over the past decade, opioid-related overdose deaths have continued to rise.

 

Court OKs denying coverage for mental health, substance-use care

If allowed to stand, a three-judge panel decision from the 9th U.S. Circuit Court of Appeals will destroy the progress that has been made in helping ensure that patients receive the medically appropriate mental health and substance-use disorder care they need and deserve, physicians tell a federal appeals court.

 

Change Healthcare Partners with the American Society of Addiction Medicine to Transform Utilization Management for SUD

The ASAM Criteria® Powered by InterQual® brings efficiency for payers and providers to assess the millions of patients suffering from substance use disorders.

 

FTC requests additional details on UnitedHealth’s acquisition of LHC Group

The Federal Trade Commission has issued a second request for information on UnitedHealth Group’s $5 billion planned acquisition of home health provider LHC Group.

 

Aetna Cancels Contract With Cerebral Over Controlled Substance Prescribing Issues

Health insurer Aetna is canceling its in-network contract with Cerebral in August, the mental health startup’s CEO told employees on Wednesday.

 

Why insurers may be breaking the law with restrictive mental health coverage

While the pandemic has put everyone’s mental well-being at risk, adolescents have taken it especially hard and have struggled with the social isolation and heightened caution of the “new normal.”

 

As Anthem Rebrands To Elevance, Healthcare Services To Be Named ‘Carelon’

Health insurer Anthem’s rebrand to Elevance Health will include the new name of “Carelon” for its healthcare services and the return of “Wellpoint” for certain government-subsidized health insurance products.