RISE summarizes recent regulatory-related headlines.
Health care spending in the US reached $4.9T in 2023
A new analysis from the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS) estimates that health care spending in the United States in 2023 reached $4.9 trillion and increased 7.5 percent, growing from a rate of 4.6 percent in 2022. The report, published this week in Health Affairs, said that in 2023, the insured share of the population reached 92.5 percent, as enrollment in private health insurance increased at a strong rate for the second year in a row, and both private health insurance and Medicare spending grew faster than in 2022. For Medicaid, spending and enrollment growth slowed as the COVID-19 public health emergency ended. The health sector’s share of the economy in 2023 was 17.6 percent, which was similar to its share of 17.4 percent in 2022 but lower than in 2020 and 2021, during the height of the COVID-19 pandemic.
UMD researcher aims to uncover ‘ghost networks’ in MA plans
Dr. Mika Hamer, a University of Maryland School of Public Health researcher, has received a $100,000 grant from the Robert Johnson Wood Foundation (RWJF) to uncover the extent of “ghost networks” in Medicare Advantage health insurance plans.
A "ghost network" describes the difference between advertised in-network health care providers for a given insurance plan and the providers who are in fact available to deliver care to patients enrolled in those plans–meaning a patient has more options on paper than in reality.
“We want patients on Medicare Advantage plans to know their true options,” Dr. Hamer said in the grant announcement. “By learning how big these ghost networks are, why they exist and who they affect most, we will then be able to offer practical policy solutions to help. We already know that accessing health care and finding doctors who are accepting new patients is a problem. This study will pinpoint exactly where and how many ghost networks exist in Medicare Advantage, and who is most affected by larger ghost networks."
Hamer's research will focus on patients' health care access, quality, and equity with regard to Medicare Advantage plans, and will examine nationwide Medicare Advantage enrollment and visit data and provider network data from 2017 to 2021. Her funding, RWJF's Health Data for Action program, has enabled researchers access to health data that is often otherwise cost prohibitive. Beyond identifying the ghost networks, the study will also examine geographic locations, race, sex, ethnicity, age, and other factors of people participating in plans with ghost networks.
New legislation introduced to protect patients from surprise medical billing
U.S. Senators Roger Marshall, M.D., (R-Kan.) and Michael Bennet (D-Colo.) this week introduced the No Surprises Act Enforcement Act, legislation that seeks to protect patients from surprise medical bills.
A 2020 law, the No Surprises Act, created a process for settling payments for patients’ costs associated with visiting a health care provider outside of their health insurance’s network for care. However, health insurance companies are not following the process outlined in this federal law, according to the lawmakers. The No Surprises Act Enforcement Act improves the No Surprises Act by ensuring health insurers reimburse providers promptly so costs are not passed along to patients.
The bill would:
- Close enforcement gaps through increased penalties for non-compliance of statutory payment deadlines
- Provide parity between penalties imposed against parties non-compliant with the law
- Increase transparency in reporting requirement
“Our legislation ensures that out-of-network medical bills are resolved promptly and fairly, with enhanced penalties for any failure by the health insurers to do so. We are fighting for patients, who often feel helpless battling the insurers and the health care industry. Let’s level the playing field and put patients’ care and positive outcomes above unfair payment practices,” Senator Marshall said in an announcement.
Texas doctor pleads guilty in $5.5M COVID-19 fraud scheme
A Texas physician pleaded guilty on Monday in connection with his role in a $5.5 million over-the-counter (OTC) COVID-19 test fraud scheme.
According to court documents, Mark Mazzare M.D., 57, of Tyler, purchased Medicare beneficiary identifiers (BINs) that were used to bill Medicare millions of dollars for OTC COVID-19 test kits, many of which had not been requested by the beneficiaries. Mazzare worked with an alleged marketer to conceal the purchase of BINs as “lead packages,” which actually consisted of BINs and fraudulently generated audio recordings claiming to be the voices of the beneficiaries requesting the OTC COVID-19 tests. Mazzare caused OTC COVID-19 tests to be shipped to Medicare beneficiaries whose BINs had been purchased, regardless of whether the Medicare beneficiaries had requested or needed the tests. From in or around November 2022 to in or around June 2023, Mazzare caused more than $5.5 million in claims to be submitted to Medicare for OTC COVID-19 tests that were medically unnecessary and ineligible for reimbursement. Medicare paid approximately $3.44 million on those claims.
Mazzare pleaded guilty to conspiracy to defraud the United States and to purchase, sell, and distribute Medicare beneficiary identification numbers. He faces a maximum penalty of five years in prison. A sentencing hearing will be set at a later date.