26 payer moves impacting ASCs in 2024

Here are 26 moves by payers for ASC leaders and physicians to know in 2024:

1. Anthem Blue Cross Blue Shield of Connecticut, New York and Missouri reversed a controversial Nov. 1 update to its anesthesia reimbursement policy. The policy update applied to procedures billed under CPT codes 00100 through 01999 and would have introduced a new reimbursement structure based on CMS physician work time values. Claims exceeding these predetermined time limits would have been denied. Anthem told Becker's that the reversal was spurred from "widespread misinformation" surrounding the update. 

2. The U.S. Justice Department filed a lawsuit against UnitedHealth Group, parent company of Optum, to block its planned $3.3 billion acquisition of home health provider Amedisys. 

3. On Nov. 1, CMS released its 2025 physician payment rule, which included a 2.83% conversion factor decrease from 2024. 

4. The Office of the Inspector General for HHS alleged in audits published Sept. 25 that subsidiaries of Aetna and Humana received millions in Medicare Advantage overpayments in 2017 and 2018. The OIG estimated that HealthAssurance Pennsylvania, an Aetna subsidiary, received $4.2 million in overpayments in that period of time. 

5. A jury ruled that Blue Cross and Blue Shield of Louisiana shortchanged a New Orleans-based surgical center by more than $400 million after a seven-year legal fight. The insurer was accused of shortchanging the center on thousands of breast reduction surgeries. 

6. On Sept. 23, the Federal Trade Commission published a redacted lawsuit filed against three pharmacy benefit managers and group purchasing organizations, including Cigna's Express Scripts. Cigna is also suing the FTC over what it called an "unfair, biased, erroneous and defamatory" report on PBMs the agency published in July. 

7. A number of health systems and hospitals have dropped Medicare Advantage plans, citing frequent reimbursement denials, escalating implant costs and increasing administrative hurdles that complicate patient care. 

8. Cigna announced it will be exiting the Medicare Advantage market or making service area reductions in eight states for 2025. In total, 36 plans and about 5,400 members will be affected. 

9. On Sept. 12, Cigna launched  an "E-Treatment" option for members to get urgent care without any direct video or phone interaction with a provider. 

10. On Sept. 11, Florida's Insurance Commissioner Michael Yaworsky signed a consent order to approve the indirect acquisition of Cigna's HealthSpring of Florida by Health Care Service Corp., the parent company of five Blue Cross Blue Shield plans. The $3.3 billion pending sale includes Cigna's Medicare Advantage, supplemental benefits, Medicare Part D offerings and CareAllies, a value-based care management subsidiary.

11. Aetna will begin covering intrauterine insemination as a medical benefit for eligible plans, a move the insurer called a "landmark policy change." IUI is usually only covered if employers offer a separate fertility benefit plan. 

12. California fined Anthem Blue Cross of California and its Medicaid subsidiary a total of $850,000 for illegally limiting coverage for gender dysphoria treatments. 

13. CVS Health CEO Karen Lynch assumed leadership of Aetna after a difficult year for the insurer. Revenue in CVS' healthcare benefits segment dropped 40% from the second quarter of 2023. Brian Kane, former president of Aetna, is no longer with the company. 

14. Medicare Advantage plans received $50 billion in payments between 2018 and 2021 for "questionable diagnoses" insurers added to medical records, an investigation by The Wall Street Journal found. The Journal investigated billions of Medicare Advantage records and found that some conditions were diagnosed at a much higher rate among Medicare Advantage beneficiaries than among traditional Medicare beneficiaries. 

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

16. Humana announced plans to open primary care clinics at 23 former Walmart Health sites. Humana will open CenterWell Senior Primary Care and Conviva Care Centers in Walmart stores in Florida, Georgia, Missouri and Texas. The clinics are expected to open in the first half of 2025.

17. Lawmakers have pressured CMS to do more to prevent misuse of AI by Medicare Advantage plans. A group of 51 lawmakers signed a letter to CMS Administrator Chiquita Brooks-LaSure asking the agency to implement more stringent oversight regarding the technology.

18. Blue Cross Blue Shield of Massachusetts expanded care options for members with back pain and musculoskeletal conditions through Vori Health. 

19. Anthem Blue Cross Blue Shield and CommonSpirit reached an agreement to keep 11 CommonSpirit Health hospitals in Colorado in Anthem's network. 

20.  Independence Blue Cross extended its value-based care agreement with Philadelphia-based Rothman Orthopaedic for three more years. The agreement includes total hip, knee and shoulder replacements, knee arthroscopy, lumbar laminectomy and spinal fusion. 

21. The largest commercial payer in Washington state implemented coverage for Centinel Spine's Prodisc L implant. 

22. A survey by the Commonwealth Fund found that Medicare Advantage members are more likely to report delays in care than those covered by traditional Medicare. Twenty-two percent of Medicare Advantage members reported waiting to receive care while awaiting insurance approval compared to 13% with traditional Medicare. Feb 21

23. Centinel Spine earned coverage from a large commercial payer in Tennessee for one- and two-level lumbar disc replacement.

24. Blue Cross Blue Shield of Massachusetts no longer covers monitored anesthesia for certain gastrointestinal patients undergoing endoscopic, bronchoscopic or interventional pain procedures. Monitored anesthesia is no longer considered "medically necessary" for these procedures, unless a patient receives documentation by the operating physician or anesthesiologist/certified registered nurse anesthetist that specific risk factors or significant medical conditions are present. 

25. Blue Cross Blue Shield of Massachusetts removed 14,000 prior authorization requirements for home care services for its 2.6 million commercial members. 

26. CMS expanded its Transparency in Coverage rule. Payers' price comparison tools are now required to include all services, including prescription drugs. Payers not in compliance could face fines of up to $100 per day for each violation. 

Copyright © 2024 Becker's Healthcare. All Rights Reserved. Privacy Policy. Cookie Policy. Linking and Reprinting Policy.

 

Articles We Think You'll Like

 

Featured Whitepapers

Featured Webinars