WSJ: How UnitedHealth’s Diagnosis Game Rakes in Billions from Medicare

By Wendell Potter - An investigative piece in the Wall Street Journal, written by Mark Maremont, Danny Dougherty, and Anna Wilde Mathews, gives an eye-popping look at how UnitedHealth Group is turning diagnosis-driven billing into a high-stakes game in the conglomerate’s Medicare Advantage business. Read Full Article…

HVBA Article Summary

1. Profit-Driven Diagnosis Inflation: UnitedHealth's practice of providing doctors with diagnosis checklists has led to the inflation of "sickness scores," which significantly increase Medicare payments. Former physicians described feeling pressured to confirm or deny often obscure or irrelevant conditions, leading to billions in additional revenue for the company.

2. Incentivizing Higher Risk Classifications: The company's internal documents reveal financial incentives for both doctors and nurses to engage with the diagnosis system, with doctors earning up to $30,000 in bonuses and nurses paid $250 per patient visit for identifying new diagnoses. This raises ethical concerns about prioritizing profit over patient care.

3. Calls for Greater Oversight: The stark contrast between traditional Medicare and Medicare Advantage patients in terms of sickness score inflation highlights systemic issues in how Medicare Advantage is structured. The Centers for Medicare and Medicaid Services is investigating these practices, signaling the need for stricter regulatory scrutiny and policy reforms.

Kamala Harris Announces New Federal Rule To Help People With Medical Debt

By Jonathan Cohn - A new federal rule will block credit agencies from including medical debt in their reports on individuals, the Biden administration announced on Tuesday. Read Full Article…

HVBA Article Summary

1. Medical Debt Relief Rule Finalized: Vice President Kamala Harris announced the finalization of a federal rule aimed at helping millions of Americans burdened by medical debt. The rule seeks to prevent medical debt from hindering access to loans, making it easier for families to obtain car loans, home loans, and small-business loans.

2. Impact and Uncertainty: While approximately 15 million Americans hold medical debt totaling around $49 billion, the effectiveness of debt relief remains uncertain. A recent study on large-scale philanthropic debt relief efforts, such as those led by RIP Medical Debt, showed limited financial improvement for affected individuals, though the organization continues to adjust its strategies for better results.

3. Broader Health Insurance Efforts: Harris and the Biden administration have prioritized expanding health insurance coverage as a fundamental solution to prevent medical debt. Policy changes under their leadership, including increased financial assistance for Affordable Care Act insurance plans, have reduced uninsured rates to historic lows. However, the future of these measures remains uncertain under the incoming Trump administration and new Republican congressional leadership.

Report: Many SMB employees face higher health care costs

By Michael Popke - As workers across the country enroll in their 2025 health insurance plans, a new report from the Commonwealth Fund reveals that small-business employees face higher health insurance deductibles and premium costs compared to their counterparts at larger companies. And despite paying more, these workers receive coverage with less financial protection. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Higher Premiums and Deductibles for Small-Firm Employees: In 2023, employees at small businesses paid $7,529 annually for family premiums — $733 more than those in larger firms — and faced higher average deductibles of $5,074 compared to $3,547 for large-firm employees.

2. State-Level Disparities in Costs: Health insurance costs for workers vary significantly by state, with small-firm employees in some states, like Massachusetts, paying nearly double the family premiums of large-firm employees. Small-firm workers in many states also contribute a higher share of premiums, such as in Arkansas where they paid 56% compared to 27% for large-firm workers.

3. Rising Costs Over Time: Since 2017, small-firm employees have consistently paid more in premium contributions while facing high deductibles. Premium contributions increased from $5,413 in 2017 to $7,529 in 2023 for small firms, reflecting a growing financial burden and the need for policy solutions to address these disparities.

Telehealth survives in federal spending plan, but fight for longer extension continues

By Ron Southwick - Healthcare advocates thought they had secured a significant extension of telehealth programs. The American Telemedicine Association and other trade groups had pressed lawmakers for action, since waivers for telehealth programs were set to expire Dec. 31. Read Full Article… 

HVBA Article Summary

1. Short-Term Extension with Key Omissions: Congress approved a short-term spending package extending telehealth and hospital-at-home programs through March 31 but omitted critical provisions, including a telehealth tax provision for high-deductible health plans, virtual care under the Medicare Diabetes Prevention Program, and the SPEAK Act for multilingual telehealth services, all set to expire on December 31.

2. Ongoing Advocacy Efforts: Kyle Zebley of the American Telemedicine Association emphasized the need for continued advocacy to secure longer extensions or permanent authorizations for telehealth and hospital-at-home services. The association plans to work with bipartisan Congressional leaders, including the new Republican majority in the Senate, to restore and expand coverage for these essential healthcare services.

3. Bipartisan Support and Future Prospects: Despite mixed results in the recent spending bill, telehealth programs have historically enjoyed bipartisan support, with both the Trump and Biden administrations backing expansions. Zebley remains optimistic about the potential for longer-term legislative support, emphasizing the broad political consensus around telehealth's value in healthcare access.

Workers with manually substantiated FSA claims less likely to forfeit funds, analysis finds

By Alan Goforth - About half of flexible spending account holders fail to maximize their tax advantages by paying for qualified medical expenses by the end of the year. As a result, they forfeited an average of $441, previous analyses of EBRI’s FSA database found. Read Full Article…

HVBA Article Summary

1. FSA Rollover and Forfeiture Rules: While some Flexible Spending Accounts (FSAs) allow up to $640 to be carried over into the next plan year, approximately one-third of FSAs operate on a use-it-or-lose-it basis, meaning any unused funds are forfeited back to the employer.

2. Simplified Spending Tools: Retailers have introduced tools to help workers maximize their FSA funds, such as FSA-eligible product filters on websites and the Inventory Information Approval System (IIAS), which automatically identifies eligible expenses at checkout, often enabling seamless auto-substantiation for reimbursement when using an FSA payment card.

3. Manual Claim Substantiation Benefits: Workers who manually substantiate claims by submitting documentation, such as receipts, are less likely to forfeit funds and forfeit smaller amounts when they do. Data shows these workers were 13 percentage points less likely to forfeit funds and, on average, forfeited $114 less than those relying solely on auto-substantiation.

Voluntary benefits billing: 5 key questions brokers should ask 

By Nick Rockwell - It’s a good bet that the voluntary partners you bring to the table for your employer clients check all the big boxes: quality products, competitive pricing, enrollment support. But after you help create a strong benefits package and wrap up the enrollment, your clients are left with a big task that lasts all year: billing. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Billing Quality and Flexibility Matter: The quality and reliability of a carrier’s billing process play a critical role in a client’s decision when choosing a voluntary benefits provider. Flexible billing options, such as multiple payment methods and compatibility with third-party administrators, can enhance the client’s experience and satisfaction.

2. Simplifying Payroll Deductions and Premium Reconciliation: Carriers that simplify payroll deductions and premium reconciliation improve billing accuracy and reduce administrative burdens. Providing electronic payroll deduction files, clear calculation instructions, and tolerance amounts for premium reconciliation ensures smoother billing operations and fewer follow-up inquiries.

3. Streamlined Claims Processing for Self-Billing Clients: Carriers that maintain individual employee records and require regular eligibility files help simplify claims processing and reduce delays. Ensuring accurate eligibility data upfront can minimize coverage verification issues, improving both the billing and claims experiences for clients and employees.

Retatrutide Produces Greatest Weight Loss

By Alicia Ault - A systematic review of 26 randomized controlled trials (RCTs) finds that among glucagon-like peptide 1 (GLP-1) receptor agonists and co-agonists on the market or still being investigated, the experimental drug retatrutide (Eli Lilly and Company) produces the greatest weight loss. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Efficacy of GLP-1 and Co-Agonist Medications: The review found that the triple agonist retatrutide produced the highest mean reductions in body weight among healthy adults with overweight or obesity, followed by the dual agonist tirzepatide and the GLP-1 agonist semaglutide. Retatrutide led to a 22% reduction in body weight after 48 weeks, while tirzepatide resulted in an 18% reduction after 72 weeks, and semaglutide a 14% reduction after 68 weeks.

2. Comparative Analysis and Limitations: No direct head-to-head trials were identified; instead, the researchers analyzed results from 26 randomized controlled trials (RCTs) with over 15,000 patients. Despite the general trend of greater weight loss with dual and triple agonists compared to single GLP-1 agonists, the authors cautioned against drawing definitive conclusions due to differences in study populations, control groups, and protocols.

3. Safety and Long-Term Use: All GLP-1 and co-agonist medications had a similar safety profile, with the most common adverse events being gastrointestinal issues (nausea, diarrhea, constipation, vomiting), affecting 60%-80% of patients, though most were transient. No serious gastrointestinal complications were reported. The review suggested that chronic use of GLP-1 medications might be necessary for sustained weight loss, as longer treatment durations showed consistent results with shorter-term trials.