Health Headlines: December 2024

MultiPlan faces additional litigation, this time from the American Medical Association (AMA), alleging collusion with commercial insurers in a price-fixing scheme to set below-market rates for out-of-market care. The United States’ largest insurers engage MultiPlan to determine out-of-network rates, with MultiPlan receiving a portion of the difference between its recommended rates and the original out-of-network bill. AMA alleges such arrangements are simply a “smokescreen for traditional price-fixing,” which forces providers to accept artificially low payments.

AMA’s lawsuit is the latest in a series of lawsuits filed against MultiPlan with similar allegations, including lawsuits filed by Community Health Systems, AdventHealth, Allegiance Health Management, and other providers, which were centralized in an Illinois federal court in August. Earlier this year, a California judge dismissed a similar lawsuit finding reimbursement rates are not prices that can be fixed under antitrust laws. MultiPlan maintains these lawsuits are meritless and plans to vigorously defend against the claims.

A copy of the complaint can be found here.

Two Anthem Blue Cross and Blue Shield (BCBS) members filed a class-action lawsuit in New York in October of this year, alleging that they paid a portion of their health insurance premiums for mental health coverage that “never existed or was grossly inadequate.” The plaintiffs allege that Anthem BCBS published a directory of mental health providers that falsely claimed all of the providers were in-network with BCBS, yet many were not.

These misleading lists or directories of mental health providers issued by health insurance companies are often referred to as “ghost networks.” Attorneys for the plaintiffs engaged in “secret shopper” surveys, through which they called the doctors on Anthem BCBS’s directory and asked them if they were in-network and accepting new patients. Of the first 100 doctors in the directory, only seven accepted insurance and were taking new patients. Several were also not actually mental health providers.

One of the firms representing the plaintiffs, Pollock Cohen LLP, issued a statement regarding the Anthem BCBS litigation that represents the firm as also investigating other large insurance companies for the same conduct alleged in the Anthem BCBS suit. A copy of the complaint can be found here.

“Ghost networks” of mental health providers have been an area of focus for legislators, including the US Senate Finance Committee and the New York Attorney General’s office.

Several healthcare deals on the horizon will involve payers acquiring providers. Carelon, Elevance Health’s health services arm, plans to buy CareBridge, a Nashville-based provider for patients with chronic and complex conditions. Humana aims to acquire Miami-based Clinical Care Medical Centers, which will integrate with CenterWell’s Primary Care Organization, and plans to open primary-care clinics at former Walmart health sites. And UnitedHealth Group is a potential bidder in the sale of Surgery Partners, an ambulatory surgical center operator.

In terms of deals closed in 2024 involving payer acquisitions of providers, Optum recently acquired CARE Counseling’s behavioral health clinics in the Minneapolis area, along with Corvallis Clinic, an Oregon-based provider. Earlier this year, Optum announced plans to buy Amedisys, a home health provider; however, the deal is still pending approval. Centivo, a self-funded health plan, acquired Eden Health, a virtual-first provider. Elevance Health acquired Kroger Specialty Pharmacy and infusion center and specialty pharmacy Paragon Healthcare. Blue Cross and Blue Shield of North Carolina bought FastMed’s North Carolina urgent-care clinic locations. And most recently, Cascade Capital Group acquired the largest nursing home chains in Iowa. The nursing home facilities were previously owned by ABCM Corp., which announced in July that operations would be transferred to Legacy Healthcare, an affiliate of Cascade Capital.

Several factors have led to significant turnover in the Medicare Advantage landscape for 2025, including the redesign of the Part D benefit due to regulatory changes included in the Inflation Reduction Act, lower-than-expected benchmark rates, the transition to the v28 Risk Adjustment model, and rising medical trends, according to a report from Oliver Wyman. The report highlighted that 1.8 million Medicare Advantage members were enrolled in plans in 2024 that will not be offered in 2025. While many insurers may continue to offer other Medicare Advantage plans within a given market, 18 marketing brands, including Premera Blue Cross and Blue Cross and Blue Shield of Kansas City, are exiting the market entirely.

The Office of the Inspector General (OIG) released a report highlighting the potential for abusive use of health risk assessments (HRAs), particularly in-home HRAs and HRA-linked chart reviews, to boost risk-adjustment payments to Medicare Advantage (MA) plans. The report notes that diagnoses reported only on MA enrollees’ HRAs and HRA-linked chart reviews (and not on any other service records in 2022) resulted in $7.5 billion in MA risk-adjusted payments for 2023. Centers for Medicare & Medicaid Services (CMS) agreed with OIG that CMS should determine whether specific health conditions drove payments from in-home HRAs and HRA-linked chart reviews (and are therefore more susceptible to misuse). Both MA plans and providers offering HRAs for MA enrollees should be aware of the increased regulatory scrutiny.