3 States Dropping Payers from Medicaid Contracts
By Rylee Wilson | October 4, 2023
Some states are opting for new providers to administer their Medicaid managed care programs.
Here are three states dropping contracts Becker’s has reported since July:
1. Indiana said it will no longer award Molina Healthcare a contract to manage a new Medicaid long-term services and supports program, according to regulatory filings from Molina. The company said it was unable to secure approval from CMS to have a dual eligible special needs program in place in Indiana by 2024. The state is proceeding with plans to award contracts to manage the program to Humana, UnitedHealthcare and Anthem Blue Cross Blue Shield.
2. New Mexico will not renegotiate a Medicaid contract with Centene subsidiary Western Sky Community Care. In August, the state said it plans to award contracts to Blue Cross Blue Shield of New Mexico, Presbyterian Health Plan, United Health Plan and Molina Health Plan.
3. Idaho dropped Optum as the managed care contractor for its behavioral health plan, awarding a four-year, $1.2 billion contract to Centene’s Magellan Healthcare subsidiary. Optum held the contract for a decade.
To read more, go to Becker’s Payer Issues.
75K Kaiser Workers Walk Off in Healthcare’s Largest Strike
By Jacqueline LaPointe | October 4, 2025
More than 75,000 unionized workers of Kaiser Permanente launched a strike today, marking the largest strike of healthcare workers in US history.
The workers represented by a coalition of eight unions walked off the job Wednesday after expressing concerns about staffing shortages, clinician burnout, and inadequate compensation. The Coalition of Kaiser Permanente Unions, which represents over 85,000 healthcare workers, said it did not reach an agreement with the health system by 6:00 AM PDT covering nurses, medical technicians, and support staff.
Kaiser Permanente is one of the country’s largest health systems with 39 hospitals nationwide. The health system also provides coverage through its insurance plans for nearly 13 million people.
The Coalition of Kaiser Permanente Unions approved a three-day strike in California, Colorado, Oregon, and Washington. A one-day strike was approved in Virginia and Washington DC.
The strike includes licensed vocational nurses, home health aides, ultrasound sonographers, and technicians in radiology, X-ray, surgical, pharmacy, and emergency departments. Physicians are not participating in this strike. In Virginia and Washington DC, the strike includes optometrists and pharmacists.
Kaiser Permanente said its hospitals and emergency departments would remain open during the strike and would be staffed by “contingency workers.” The health system also told news sources on Wednesday that “management and coalition union representatives are still at the bargaining table, having worked through the night in an effort to reach an agreement.”
Strikes have been popping up across the nation and across industries this year as workers deal with a shaky economy and labor shortages post-pandemic. Healthcare, in particular, has experienced record-high levels of clinician burnout and persistent clinician shortages since the height of COVID-19.
The unions of Kaiser workers have been pressing for better wages of at least $25 per hour and more staff to support operations. They say the health system needs to hire 10,000 new healthcare workers to fill current vacancies.
Unionized workers argue that understaffing is cushioning Kaiser Permanente’s bottom line despite detriments to patient care. Executives have also engaged in bad faith negotiations, resulting in the strike, according to the unions.
To read more, go to Revcycle Intelligence.
American College of Radiology, RBMA Express Growing Alarm Over Pause in Surprise-bill Processing
By Marty Stempniak | October 3, 2023
Radiology societies are expressing growing alarm over the extended closure of the process specialists use to settle out-of-network payment disagreements with insurers.
The federal government shut down independent dispute resolution, or IDR, in early August after a judge struck down the 600% increase to the fee physicians must pay to initiate mediation. IDR has remained largely inactive since then, with requests from radiologists and other physicians continuing to pile up in the eight-week aftermath.
Five physician groups, including the Radiology Business Management Association and American College of Radiology, on Monday pressed the feds for a “immediate and full” IDR relaunch.
“The already substantial backlog of arbitration cases grows worse each passing day,” ACR, RBMA, the American Society for Anesthesiology, the Emergency Department Practice Management Association and the American College of Emergency Physicians said in a joint statement issued Oct. 2. “Clinicians face considerable cash-flow challenges that are being compounded by their lack of recourse in resolving payment disputes.”
ACR et al. said they appreciate the Centers for Medicare & Medicaid Services in September instructed arbitrators to begin processing claims submitted prior to Aug. 3. However, the announcement applied only to singular, one-off disputes and not those that have been batched together for efficiency’s sake. This is only “further straining the IDR system,” the medical groups contend.
Radiologists, anesthesiologists and emergency physicians also want the federal government to reform “overly restrictive” rules applying to the batching together of similar claims.
“Without a change to these rules, the IDR system will remain overwhelmed by single, inefficient claims that add administrative burdens to the healthcare system as a whole and detract resources from patient care,” ACR, the RBMA and others said Monday.
“These kinds of barriers and delays in dispute resolution undermine the well-crafted and interconnected policies of the No Surprises Act that serve to protect patients from surprise medical bills. The law cannot function as intended while its most crucial functions remain inaccessible.”
The medical groups labeled the weeks-long stoppage as “unnecessary,” while noting that the Texas judge’s ruling that proceeded the pause “made clear that dispute resolution could continue uninterrupted.”
In related No Surprises Act news, the federal government also recently proposed raising the IDR fee from $50 (which it fell back to following the ruling) up to $150. ACR also submitted testimony to the U.S. House Committee on Ways & Means regarding ongoing issues with the No Surprises Act.
To read more, go to Radiology Business.
Survey Says Most Women Skip Their Recommended Mammogram
By Chad Van Alstin | October 3, 2023
Women cite a lack of time as the primary reason for not scheduling a mammogram, MedStar Health reported Oct. 2.
The organization’s new consumer survey shows that, despite annual breast cancer awareness campaigns, celebrity sponsorships, and sports teams dressing in pink, most women are not getting their annual recommended mammogram. About 59% of women admit to forgoing the recommended annual mammogram, while another 23% say they’ve never had one at all. The survey was conducted by MedStar Health, a large not-for-profit health system in Maryland.
These findings come at a time when breast cancer diagnoses continue to rise, with an annual increase of about 0.5%, according to the American Cancer Society.
Notably, there has been a nearly 3% uptick in diagnoses among younger women under 40. This shift in statistics led the United States Preventative Task Force (USPSTF) to lower its recommended age for mammograms from 50 to 40 in May.
“Everyone’s breast cancer risk is different. Educating yourself about your own risk is key to catching it early,” physician assistant Stephanie Johnson, director of the MedStar Health’s High-Risk Breast Cancer Program, said in a statement. “The American College of Radiology recommends that every woman calculate her risk with the Tyrer-Cuzick risk model at age 30 and about every five years after. This model considers at least eight factors for risk.”
The survey delved into the reasons behind women’s reluctance to undergo mammograms. The top reasons cited by women included not finding the time (34%), having a normal mammogram in the past (21%), and lacking a family history of breast cancer (17%).
Additionally, the survey uncovered some disparities in awareness, with 62% of respondents saying they did not know that age is a risk factor. When it comes to lifestyle risks, 56% of those surveyed said they did now know cigarette smoking increased the risk of getting breast cancer.
To read more, go to Health Imaging.
Cigna Will Pay $172M for Allegedly Filing False Claims that Lacked Necessary Imaging to Back Diagnosis Codes
By Marty Stempniak | October 2, 2023
Cigna has agreed to pay $172,294,350 to settle allegations that it violated the False Claims Act, including submitting diagnosis codes unsupported by necessary medical imaging, authorities announced Saturday.
Under the Medicare Advantage program, the Bloomfield, Connecticut-based insurer would purportedly base such diagnoses on in-home patient assessments of beneficiaries typically conducted by nurse practitioners. These NPs would often diagnose serious, complex conditions without the necessary medical imaging or diagnostic tests to reach such conclusions, the Department of Justice said.
Other healthcare providers who saw these patients did not report such diagnoses to Cigna during the year in which the home visits occurred.
“For years, Cigna submitted to the government false and invalid diagnosis information for its Medicare Advantage plan members,” Damian Williams, U.S. Attorney for the Southern District of New York, said in a Sept. 30 announcement from the DOJ. “The reported diagnoses of serious and complex conditions were based solely on cursory in-home assessments by providers who did not perform necessary diagnostic testing and imaging.
Cigna knew that these diagnoses would increase its Medicare Advantage payments by making its plan members appear sicker.”
Cigna owns and operates organizations that offer Medicare Advantage plans to beneficiaries across the country. Authorities allege that the insurer submitted “inaccurate and untruthful” diagnosis data to inflate payments received from CMS. The company also purportedly failed to withdraw this data and repay CMS, and it falsely certified in writing that the data was accurate. The DOJ further alleged that between 2014 to 2019, Cigna ran a “chart review program” that did not properly substantiate diagnosis codes submitted to CMS.
Along with paying the settlement, Cigna is entering into a five-year corporate integrity agreement with the HHS Office of Inspector General. Under the pact, Cigna must implement “numerous” accountability and auditing provisions, including requiring top execs and board members to certify that Cigna is following the proper compliance measures. The insurer also must perform annual risk assessments and other monitoring, with an independent reviewer conducting regular audits.
The civil settlement of the home visit-related allegations comes after a whistleblower filed suit under the False Claims Act last year, with the feds later joining the complaint. Robert A. Cutler—former part-owner of a vendor retained by Cigna to conduct the home visits—stands to receive $8.14 million from the settlement under provisions of the FCA.
To read more, go to Radiology Business.
CMS Agrees to Broaden MRI Pay Policy in Response to Radiology Societies’ Advocacy Campaign
By Marty Stempniak | September 28, 2023
An advocacy campaign from five radiology groups has paid off, with the Centers for Medicare & Medicaid Services agreeing to broaden its payment policy for a crucial MRI exam.
The Society for Cardiovascular Magnetic Resonance teamed with RSNA, the American College of Radiology and others, writing letters and making phone calls to the federal agency. Their concerns stemmed from the use of cardiac MRI for velocity flow mapping, a technique that provides a display of the cardiovascular system at work.
CMS’s policy permits billing for the procedure a single time. However, imaging providers often must take multiple measurements, where medically necessary, for certain patients, including those with congenital heart defects.
The agency has now relented and agreed to allow radiologists and other providers to bill for CPT 75565 more than once in a visit, beginning on Oct. 1.
“We know that some of our most complex patients are those with congenital heart disease—and that the time it takes to evaluate them is extraordinary and a labor of love,” Carrie Kovar, a consultant to the Society for Cardiovascular Magnetic Resonance, wrote in a Sept. 28 news update. “After back and forth correspondence, and multiple phone calls, we are thrilled to announce that this campaign was successful,” she added later.
The American Roentgen Ray Society and Association of University Radiologists also joined in the advocacy effort.
Beginning on Sunday, imaging providers can bill for 75565 up to four times per patient per day. The Society for Cardiovascular Magnetic Resonance noted that this is an add-on code. As such, it should be reported in conjunction with cardiac MRI for morphology and function (without contrast) material codes 75557, 75559, 75561 and 75563.
“It is important to document what valves/vessels/shunts/baffles you obtained flows on in the report, and state the numbers clearly,” the society said in a separate announcement, while also sharing an example.
CMS posted this revision in an update shared earlier this month. The American College of Radiology also alerted its members about the change in a Sept. 22 news post.
The Society for Cardiovascular Magnetic Resonance urged anyone with questions to contact their local Medicare Administrative Contractor.
To read more, go to Radiology Business.