A study conducted by PwC showed that healthcare costs are expected to rise 7% next year due to inflation which is causing providers to seek rate increases from insurers and as pharmaceutical costs increase. As in other industries, labor shortages and high labor costs are driving providers to ask for more reimbursements from insurers. High-cost drugs and supply shortages are also taking a toll on healthcare costs. Read more on our website.
Providers working with multi-year contracts have felt the pinch of inflation, labor, and supply shortage, however until contracts were up for renewal, the provider wasn’t able to be reimbursed. As contracts are renewed, providers are looking to pass on the extra cost of doing business to payers. Additionally, there is a demand for care as patients who put off care during the pandemic now seek those services. Additionally, supply chains for prescriptions have been disrupted which again drives up the cost of medication. And recently, as popular new obesity and diabetes drugs with no generic equivalents have hit the market, the demand for these treatments is hitting payers in the pocketbook. As the healthcare market continues to evolve, providers and payers will be looking for ways to reduce overall costs.
Source: Healthcare Dive
The pandemic and rise of the need for telehealth services caused a surge in fraudulent schemes. By April 2020 half of all primary care visits were through telehealth, so as reimbursement from insurers as well as government entities increased, so did the fraud. Read more on our website.
The government is taking notice of the fraud, and the Department of Justice recently arrested a ring of suspects accused of submitting $2 billion in fraudulent telehealth claims. The problem is widespread enough that the Health and Human Services Office of Inspector General issued an official fraud alert to insurers and consumers. The fraud occurs when providers are issued kickbacks for orders for unnecessary equipment, testing, wound care, or prescription medications, and those costs are passed on to insurers, including Medicare and Medicaid.
A federal statute called the Anti-Kickback statute holds providers and physicians equally responsible for telehealth fraud if they are employed by an unethical telehealth company.
Source: JD Supra
Employers and payers are always looking to reduce the cost of healthcare while still providing the best benefits for their teams and members. One way to reduce costs is with an Rx optimization program. These programs help reduce wasteful spending on prescription drugs by identifying and addressing wasteful spending and then addressing issues that aren’t currently addressed by other cost-reducing measures. Read more on our website.
The return on investment for employers can exceed 3 to 1 which means the savings is more than the cost of the program. These programs also help consumers to be more educated about the drugs in their formulary so they can work with their providers to find the best medication at the best price. Rx optimization plans are not provided with pharmacy benefit managers and carriers and as such don’t disrupt existing plans—it’s simply another layer of cost saving.
Weight loss medications including Ozempic, Wegovy, and Mounjaro are becoming increasingly popular as a treatment for obesity and diabetes. Unfortunately, while these drugs are highly effective, they are also expensive. Many employers are now trying to find the balance between providing benefits for these life-changing drugs, and the cost, which can be as much as $17,000 per year per employee. Read more on our website.
As a result, employers are seeking to find ways to ensure that the people who need the medication the most are the ones who can receive it. For maximum effectiveness, the drugs have to be taken in perpetuity, which is sure to keep costs higher. Employers are reaching out to providers to provide a more holistic approach, in which medication is combined with behavioral changes to achieve and sustain weight loss. As the popularity of these medications continues to rise, the healthcare industry and employers will continue to look for ways to provide sustainable interventions for those with obesity.
Source: Employee Benefit News
Kraft Heinz is suing Aetna for violating its fiduciary duties by allowing $1.3 billion in claims “that never should have been paid”. Kraft Heinz has a self-funded health care plan and relies on Aetna to review and adjudicate claims for health benefits. The food and beverage giant claims that Aetna failed to properly monitor these claims and in some cases overpaid, or paid fees to a company for repricing that Aetna also owns. Read more on our website.
Kraft Heinz cites a HIPAA statute that established standards for “preservation and dissemination” of medical claims data and alleges when asked for this data, Aetna failed to provide it, and when it finally did, the data was “cherry-picked”. Kraft Heinz also accuses Aetna of cross-plan offsetting.
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