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MSIS, Inc., 3250 North Valdosta Road, Valdosta, GA (2026)

09/18/2024

9 Major Medicare Changes for 2025 and How They'll Impact Your Coverage

1. You Won’t Spend More Than $2,000 for Drug Copays and Coinsurance Under Part D
2. Medicare Advantage Plans That Include Part D May Raise Costs or Reduce Coverage
3. You Can Choose to Pay Your Drug Copays and Coinsurance Over Time
4. Part B and Standalone Part D Premiums May Change
5. Other Standalone Part D Costs Could Increase
6. You'll Receive a Mid-Year Notice About Unused Medicare Advantage Benefits
7. You'll Have Better Access to Lower-Cost Biosimilar Prescription Drugs
8. Your Access to Mental Health Professionals May Increase
9. Medicare Advantage Plans Must Examine the Impact of Prior Authorizations

Wave goodbye to the Part D "donut hole" and hello to a $2,000 cap on the amount you'll pay for medications. But other changes may be less welcome. Here's what to expect.

07/15/2024

A federal judge on Friday sentenced former Georgia Insurance Commissioner John Oxendine to serve three-and-a-half years in prison after Oxendine pleaded guilty to conspiracy to commit health care fraud.....

Oxendine stood up before doctors who worked for (Dr. Jeffrey) Gallups at a September 2015 meeting at a Ritz-Carlton hotel in Atlanta and urged them to order unnecessary medical tests on patients and bill insurers, Oxendine said. Oxendine devised a plan to collect $260,000 in kickbacks from medical testing company Next Health through his consulting firm and funnel most of the money to Gallups, prosecutors said.....

Oxendine ran for governor in 2010 but lost the Republican primary. The Georgia Ethics Commission began investigating campaign finance violations in 2009, alleging Oxendine illegally used campaign funds to buy a house, lease luxury cars and join a private club.

Oxendine settled that case with the commission in 2022, agreeing to hand over the remaining $128,000 in his campaign fund while admitting no wrongdoing.

He was also accused of accepting a $120,000 bundled contribution, 10 times the legal limit, from two Georgia insurance companies when he was running for governor. A judge ruled state officials waited too long to pursue Oxendine on those charges.

A federal judge sentenced former Georgia Insurance Commissioner John Oxendine to serve three-and-a-half years in prison after Oxendine pleaded guilty to health care fraud.

07/11/2024

"With CMS estimating a fifth consecutive year of Medicare payment reductions—this time by 2.8 percent— it’s evident that Congress must solve this problem. In addition to the cut, CMS predicts that the Medicare Economic Index (MEI) – the measure of practice cost inflation—will increase by 3.6 percent."......

Medicare physician payment declined (PDF) 29% from 2001 to 2024, adjusted for inflation.

“The death by a thousand cuts continues. Rural physicians and those treating underserved populations see this CMS warning as another reminder of the painful challenges they face in keeping their practices open and providing care. It’s crucial that we ensure both continue.”

Facing a widening gap between what Medicare pays physicians and the cost of delivering care, physicians urge Congress to pass reforms to strengthen Medicare.

07/08/2024

Some diagnoses claimed by insurers were demonstrably false, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert.

“It’s anatomically impossible,” said Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham. “Once a lens is removed, the cataract never comes back.”

Insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments to the company, the Journal’s analysis showed. UnitedHealth’s net income that year was about $17 billion......

Sometimes, insurers didn’t remove potentially outdated diagnoses. The Journal’s analysis found that between 2018 and 2021, nearly 50,000 Medicare Advantage patients completed a course of high-cost drugs that almost always cures hepatitis C, a virus that can cause serious liver damage.

Insurers subsequently told Medicare that more than half of the patients who had received the drug treatment still had hepatitis C in a future year, leading to millions of dollars in extra payments. The diagnoses came from the insurers’ chart reviews and assessments, and from physician claims that insurers didn’t correct.

“They’re totally wrong,” said Douglas Dieterich, director of the Institute for Liver Medicine at Mount Sinai Health System in New York. “Real world evidence is a 99% cure rate.”

Medicare Advantage has cost the government an extra $591 billion over the past 18 years, compared with what Medicare would have cost without the help of the private plans, according to a March report by the Medicare Payment Advisory Commission, or MedPAC, a nonpartisan agency that advises Congress. Adjusted for inflation, that amounts to $4,300 per U.S. tax filer.......

Questionable diagnoses of HIV and other maladies triggered extra Medicare Advantage payments. “It’s anatomically impossible,” said one doctor about some cataract diagnoses.

07/08/2024

Some diagnoses claimed by insurers were demonstrably false, the Journal found, because the conditions already had been cured. More than 66,000 Medicare Advantage patients were diagnosed with diabetic cataracts even though they already had gotten cataract surgery, which replaces the damaged lens of an eye with a plastic insert.

“It’s anatomically impossible,” said Dr. Hogan Knox, an eye specialist at University of Alabama at Birmingham. “Once a lens is removed, the cataract never comes back.”

Insurer-driven diagnoses by UnitedHealth for diseases that no doctor treated generated $8.7 billion in 2021 payments to the company, the Journal’s analysis showed. UnitedHealth’s net income that year was about $17 billion......

Sometimes, insurers didn’t remove potentially outdated diagnoses. The Journal’s analysis found that between 2018 and 2021, nearly 50,000 Medicare Advantage patients completed a course of high-cost drugs that almost always cures hepatitis C, a virus that can cause serious liver damage.

Insurers subsequently told Medicare that more than half of the patients who had received the drug treatment still had hepatitis C in a future year, leading to millions of dollars in extra payments. The diagnoses came from the insurers’ chart reviews and assessments, and from physician claims that insurers didn’t correct.

“They’re totally wrong,” said Douglas Dieterich, director of the Institute for Liver Medicine at Mount Sinai Health System in New York. “Real world evidence is a 99% cure rate.”

Medicare Advantage has cost the government an extra $591 billion over the past 18 years, compared with what Medicare would have cost without the help of the private plans, according to a March report by the Medicare Payment Advisory Commission, or MedPAC, a nonpartisan agency that advises Congress. Adjusted for inflation, that amounts to $4,300 per U.S. tax filer.......

The ruling applies to all Medicare agents, not just the parties to the suit.

07/02/2024

Attorney General Merrick Garland announced the charges against doctors, nurse practitioners and others across the U.S. accused of a variety of scams, including a $900 million scheme in Arizona targeting dying patients....

Nurse practitioners were pressured to apply the wound grafts to elderly patients who didn't need them, including people in hospice care, the Justice Department said. Some patients died the day they received the grafts or within days, court papers say. In less than two years, more than $900 million in bogus claims were submitted to Medicare for grafts that were used on fewer than 500 patients, prosecutors said....

Gehrke and King lived lavishly off the scheme, prosecutors allege, citing luxury cars, a nearly $6 million home and more than $520,000 in gold bars, coins and jewelry. Officials seized more than $52 million from Gehrke's personal and business bank accounts after her arrest, prosecutors say.

In total, 193 people — including 76 doctors, nurse practitioners, and other licensed medical professionals — were charged in a series of separate cases brought over about two weeks in the nationwide health care fraud sweep. Authorities seized more than $230 million in cash, luxury cars and other assets.

The Justice Department has charged nearly 200 people in a sweeping crackdown on health care fraud schemes nationwide with false claims topping $2.7 billion

06/26/2024

When President Biden signed the IRA in 2022, Democrats in Washington boldly promised the law would lower Medicare costs for America's seniors. They touted the newfound ability of Medicare to set prices on popular drugs starting on January 1, 2026, along with the law's $2,000 cap on annual out-of-pocket prescription costs and its 6% limit on yearly increases in Part D premiums. Among those drugs subject to the first round of controls are Eliquis, Jardiance, and Enbrel.

Unfortunately, they neglected to inform seniors who's paying for those savings. The answer? Seniors themselves—through skyrocketing premiums hidden behind Washington accounting gimmicks.....

In 2006, the first year that Medicare Part D was available, insurers offered 1,429 plans to seniors nationwide. This year, insurers offered just 709—a decline of more than 50%. In the past year alone, the number of plans that seniors could choose from dropped by 11%.

And those plans are considerably more expensive now, post-IRA passage, on average. The typical standalone Part D plan costs seniors $48 per month, a 21% increase compared to last year. Even steeper increases are projected for 2025....

The root of the problem is that the IRA's price controls are primarily designed to save the government money, not seniors. And the provisions that genuinely do save some seniors money—like the $2,000 cap on out-of-pocket drug spending—ultimately shift costs onto insurers, and CMS is turning a blind eye to their cost-saving tactics.

Although lawmakers tried to cap premium increases, the way it was written isn't what Democrats advertised at all. It applies only to one of the underlying calculations used in setting monthly premiums. Any given plan's monthly cost to seniors can go up by 20%-40% while still remaining in compliance with the 6% increase. That's Washington math for you.

The reality is that the IRA is slowly, but predictably, destroying Medicare's "Part D" drug benefit.

06/18/2024

We’re in the second year of a three-year period in which the Centers for Medicare and Medicaid (CMS) is reducing Medicare spending with special attention directed at lowering Medicare Advantage spending, the CEO of UnitedHealth warned in a recent earnings call.
Another warning came from CVS Health, which owns and operates Aetna Medicare Advantage plans. CVS recently announced that its first quarter earnings were below expectations and 2024’s earnings would be lower than the estimate it issued three months earlier.
CVS aggressively marketed its Medicare Advantage business for 2024, enrolling about 200,000 more members than it expected. It also purchased a medical clinic business directed at seniors and a home health care company that caters primarily to Medicare beneficiaries.
Another warning was issued earlier this year by Humana, which said its Medicare Advantage business wasn’t doing as well as expected.
Both CVS and Humans said it would take at least a couple of years to restore profit margins in their Medicare Advantage plans.
As the companies were expanding their Medicare Advantage businesses, government regulators began planning to reduce payments to insurers. Medicare officials recently announced that Advantage plan reimbursements in 2025 will be less than insurers were expecting.
In addition, members’ use of medical services increased beyond the companies’ estimates.
Medicare officials also are making tweaks in what the program covers that aren’t widely announced.
For example, the program recently said that in most cases it no longer will pay for blood tests that can detect early signs an organ transplant is being rejected by the patient’s body. Instead, patients have to wait until there are enough symptoms to warrant a biopsy, according to recent editorials in The Wall Street Journal.
Expect more coverage reductions like this in both original Medicare and Medicare Advantage.
During open enrollment this fall, Medicare Advantage members should closely scrutinize information from their current plans with details of changes for 2025.
They also should develop backup plans in case the 2025 changes make the plan unattractive. A backup plan could include switching to original Medicare and adding Medicare supplement and Part D prescription drug policies. Another alternative is to review the terms of other Medicare Advantage plans offered in the area.

Medicare Advantage plans are likely to have big changes in 2025, raising premiums and out-of-pocket costs while reducing benefits.

06/18/2024

Amazon Pharmacy’s RxPass now offers Prime members on Medicare unlimited access to 60 eligible prescription medications for just $5 a month, plus fast, free delivery....

Through RxPass, Amazon Pharmacy offers up to 80% off the cost of generics and up to 40% off the cost of brand name medicines for members with or without insurance....

U.S. spending in the Medicare program for people over the age of 65 and the disabled is projected to have grown by 8.4% to over 1 trillion in 2023, according to federal government data....

RxPass could help reduce Medicare spending by nearly $2 billion annually and help lower out-of-pocket costs for older adults, Amazon said.

Amazon Pharmacy’s RxPass now offers Prime members on Medicare unlimited access to 60 eligible prescription medications for just $5 a month, plus fast, free delivery.

06/17/2024

The recalculation comes after two lawsuits over the Star Ratings, filed by insurers SCAN Health Plan and Elevance Health (ELV.N). Both insurers won their challenges last week.

(The move could deliver hundreds of millions in additional bonus payments to insurers next year, benefiting Medicare insurers at a time when their business is under pressure from rising healthcare costs and lower-than-expected rates for next year, according to the report.)

The Centers for Medicare & Medicaid Services said it will recalculate this year's quality ratings of Medicare Advantage plans for people aged 65 years and above, which would likely increase the bonus payments for insurers.

06/07/2024

The steep prices — and popularity — of Ozempic and similar weight-loss and diabetes drugs could soon make them a priority for Medicare drug price negotiations. List prices for a month’s supply of the drugs range from $936 to $1,349, according to the Peterson-KFF Health System Tracker.
..Medicare shelled out $5.7 billion in 2022 for three popular GLP-1 drugs, up from $57 million in 2018, according to research by KFF. The “outrageously high” prices have “the potential to bankrupt Medicare, Medicaid, and our entire health care system,” Sen. Bernie Sanders (I-Vt.), who chairs the Senate Committee on Health, Education, Labor and Pensions, wrote in a letter to Novo Nordisk in April.

That spending will continue to skyrocket as the benefits of these drugs pile up. Medicare can’t cover the drugs for weight loss alone, but the program does cover them when prescribed to treat diabetes. Wegovy, a version of Ozempic, has also been approved to treat heart disease and the compound has shown promise in treating kidney disease.

Lilly’s Trulicity and Novo Nordisk’s Ozempic have rocketed into Medicare’s top-10 spending list. That sets them up to be subject to price negotiations — soon.

06/04/2024

"The dirty little secret with the Inflation Reduction Act is that it is significantly increasing the premiums that seniors will pay for their Medicare drug benefits" said Joel White, president of the Council for Affordable Health Care Coverage.

Basically, while some out of pocket drug costs might come down a bit, the drug benefit premiums that seniors are going to have to pay are going to double, if not more.

"In Texas, a senior that might have a $200 a month prescription drug benefit plan premium, that premium has increased significantly this year" White told KTRH, "When the senior signs up for a plan in 2025, their premiums are going to double."

The increase this year in 2024 has already been 22%. And while Biden may boast about as his "signature achievement in health care", seniors are set to receive their notification letters in October, right before the election.

Drug prices may come down, but premiums could rise by 100%

MSIS, Inc.

09/18/2024

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Tuesday	8am - 5pm
Wednesday	8am - 5pm
Thursday	8am - 5am
Friday	8am - 12pm