MEDICARE ADVANTAGE PLANS: Rates Substantially Increased for 2026

By Health Capital Consultants LLC

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On April 7, 2025, the Centers for Medicare & Medicaid Services (CMS) published their 2026 Rate Announcement for Medicare Advantage (MA) and Medicare Part D Prescription Drug Plans.

For 2026, the payment rate to MA plans will increase 5.06%, the largest increase in the past ten years, and up significantly from the 2.2% rate increase proposed by the Biden Administration.

This Health Capital Topics article will review the Rate Announcement. (Read more…)

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Medicare Advantage [Part C] Plans Face Headwinds

By Health Capital Consultants, LLC

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With the annual enrollment period for Medicare Advantage (MA) plans slated to open in less than two months, many MA plans are cutting benefits and provider payments, while approving fewer claims. Further, after a decade of accelerated growth in the MA market, several MA plan executives have announced MA market exits and decreases in membership for the upcoming plan year.

CITE: https://www.r2library.com/Resource

This Health Capital Topics article discusses recently announced MA market exits, the reasons for those exits, and the current environment in which MA plans are operating. (Read more...)

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MEDICARE PART C: Humana Used A.I. Tool from UnitedHealth to Deny Medicare Advantage Claims

LAWSUIT

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Humana Used AI Tool from UnitedHealth to Deny Medicare Advantage Claims 

Humana used an artificial intelligence tool owned by UnitedHealth Group to wrongfully deny Medicare Advantage [Part C] members’ medical claims, according to a class-action complaint filed on Dec. 12th. The lawsuit was filed in the U.S. District Court for the Western District of Kentucky and is the latest legal action against major insurers such as UnitedHealthcare and Cigna for allegedly using automated data tools to wrongfully deny members’ claims.

The complaint against Humana, the country’s second-largest Medicare Advantage insurer, accuses the company of using an AI tool called nH Predict to determine how long a patient will need to remain in post-acute care and overrides physicians’ determinations for the patient. The plaintiffs claim Humana set a goal to keep post-acute facility stay lengths for MA members within 1% of nH Predict’s estimations. Employees who deviate from the algorithm’s estimates are “disciplined and terminated, regardless of whether a patient requires more care,” the lawsuit alleges. When decisions made by the algorithm are appealed, they are allegedly overturned 90% of the time.

Source: Jakob Emerson  Becker’s Payer Issues [12/13/23]

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PODCAST: The Real Secret About Why Corporate Mergers Fail

AN AUDIO PRESENTATION

 

By Vitaliy Katsenelson CFA

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Corporate acquisitions often fail for one simple reason: the buyer pays too much. An old Wall Street adage comes to mind: Price is what you pay, value is what you get.

It all starts with a control premium

When we purchase shares of a stock, we pay a price that is within pennies of the last trade. When a company is acquired, the purchase price is negotiated during long dinners at fine restaurants and comes with a control premium that is higher than the latest stock quotation.

How much above?

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™8Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

 

Obama on the SGR Physician Payment Formula

Solo Doctors and and Small Group Practices May Benefit

By Staff Reporterscoins3

According to Diana Manos of Healthcare Finance News, on March 23, 2009, small medical group practices and solo and/or independent physicians may benefit most from the recently proposed Obama healthcare budget. In it, President Obama asked Congress for $76.8 billion for the Department of Health and Human Services [DHHS] for fiscal year 2010. Some funding would come from changes to the way healthcare is provided, with a new emphasis on pay-for-performance [P4P] for Medicare providers.

The AMA’s Response   

It was reported that, Joseph M. Heyman, MD, chairman of the American Medical Association’s Board of Trustees, said the AMA is pleased with the administration’s proposed new baseline – or projected spending over a period of time – or Medicare physician payment updates.

“Unlike previous budget forecasts, the administration’s new budget baseline recognizes that Congress needs to and will act to avert the serious access crisis that looms as physicians face drastic payment cuts in the coming decade due to the failed Medicare physician payment formula,” he is reported to have said. Furthermore,  

“The AMA strongly supports the use of a realistic baseline as a foundation for Congress to move forward with a permanent solution to the flawed SGR physician payment formula, and urges the committee and Congress to ensure that a new Medicare physician payment baseline is adopted in the 2010 Fiscal Year (FY) Budget Resolution.”

Assessment

Under the president’s budget request, Medicare Advantage would be revamped; physicians and hospitals could expect to be paid for performance [P4P] under Medicare; pharmaceutical companies would face steeper competition from generic drug companies and the government would clamp down on inadvertent and fraudulent overpayments under Medicare. The budget also calls for “comprehensive, but fiscally responsible reforms” to the physician payment formula [Sustainable Growth Rate], moving toward rewarding doctors for efficient quality care.

Link: http://www.healthcarefinancenews.com/news/small-physician-practices-can-expect-real-changes-healthcare-under-obama-budget

Conclusion

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