Managed Care Operations
Expert articles and analysis related to managed care operations.
AI Summary — Last 30 Days
Managed care operations are facing sharper scrutiny as HHS OIG found the three largest Medicare Advantage organizations denied prior authorization for long-term acute care and inpatient rehabilitation at some of the highest rates, while separate OIG findings show many SNF denials are later overturned—intensifying pressure on MA plans’ utilization management, appeals integrity, and post-acute network strategy (OIG/MA prior authorization findings). At the same time, the Trump administration’s CMS pause on new hospice and home health Medicare enrollment signals a tougher program-integrity posture that could constrain post-acute capacity just as ACOs, hospitals, and MA plans rely on home-based and facility-based partners to manage total cost of care. Providers are responding by renegotiating or exiting weak MA contracts, reassessing provider-sponsored plans, and preparing for ACA plan margin pressures to spill into hospital reimbursement—making payer contracting, data-sharing, and care access controls central strategic issues for VBC leaders.
Related Articles
The Myth of Insurance Networks
How America’s outdated insurance model is failing at its most important job The post The Myth of Insurance Networks appeared first on MedCity News.
Northwell, Fidelis face network split affecting 240,000 patients
Northwell, Fidelis face network split affecting 240,000 patients Becker's Hospital Review
Medicare Advantage Quietly Drops Your Doctor Mid-Year. You’re Locked In Until January.
Medicare Advantage Quietly Drops Your Doctor Mid-Year. You’re Locked In Until January. AOL.com
Study finds cancer patients on Medicare Advantage access fewer providers than Medicare patients
When cancer patients see fewer providers, it’s not clear if MA is optimizing or shrinking care.
OIG report raises red flags about maternal health 'ghost networks' in Medicaid managed care
OIG report raises red flags about maternal health 'ghost networks' in Medicaid managed care Fierce Healthcare
Cancer Center Network Breadth Not Linked to Lower MA Disenrollment Rates
Mental health ghost networks are badly hurting patients
Mental health ghost networks are badly hurting patients KevinMD.com
1 in 4 on maternal health managed Medicaid network lists are ‘ghost providers’ - beckerspayer.com
1 in 4 on maternal health managed Medicaid network lists are ‘ghost providers’ beckerspayer.com
OhioHealth Settlement Signals Growing Antitrust Risk in Managed Care Contracting
In two recent civil antitrust complaints, the Antitrust Division of the U.S. Department of Justice (“DOJ”) alleged that hospital systems used payer contracting provisions—so‑called steering restrictio...
A ridiculously stupid letter from a health insurer
By MATTHEW HOLT It’s hard to imagine but I may now be in possession of the stupidest letter I’ve ever received from an American health insurance company–-and I’m the guy who gotContinue reading...