Payer Roundup—Sovereign Health sues Anthem for directly paying patients

Anthem headquarters
A healthcare facility is suing Anthem for directly reimbursing patients. (Anthem)

Sovereign sues Anthem for directly paying patients

Sovereign Health is suing Anthem, alleging that the insurance company paid patients directly for services in order to force the health system to join its network.

Sovereign operated behavioral health and substance abuse facilities in five states and was closed in 2018 due to financial troubles. The lawsuit says Anthem paid patients $1.3 million for services provided by Sovereign, an out-of-network provider. In actuality, patients are then supposed to pay Sovereign, which does not always happen. 

Barbara L. McAneny, M.D., president of the American Medical Association, called this practice of anti-assignment provisions a “bully tactic” to force providers to join networks. (BenefitsPRO)

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CMS hires first chief healthcare informatics officer

The Centers for Medicare & Medicaid Services (CMS) has named Mark Roche, M.D., as the agency’s first chief healthcare informatics officer.

A former professor at Northwestern University and National Institutes of Health researcher focused on medical informatics and healthcare interoperability, Roche also served as an adviser for Office of the National Coordinator for Health IT. 

HHS recently proposed rules that would give government health plan members control over their own health information by 2020. The announcement has sped up the need for the CMS to bring on an employee to lead the data exchange from one plan to another.

“The truth is, as the largest healthcare payer in the country, CMS should have had a CHIO function long ago,” CMS Administrator Seema Verma said in a statement. (MedCity News)

PBM transparency bill makes it past first hurdle in Georgia House

A bill taking aim at pharmacy benefit managers has passed the Georgia House of Representatives and is now headed to the state Senate.

Sponsored by Rep. David Knight, a Republican, House Bill 323 would require PBMs to report to the state Department of Insurance how much they are receiving in rebates from pharmaceutical manufacturers and how much is not being passed on to patients. 

The bill is the latest salvo in the battle for transparency in the pharmaceutical supply chain, but some advocacy groups are saying it is not enough, as the bill would not require the information to be public. (Atlanta Journal-Constitution)

U.S. spends more than $10,000 per person on healthcare annually

The U.S. government spent $10,209 per person on healthcare in 2017, more than any other country in the OECD 36-country consortium.

Individually, most adults shelled out between $4,500 and $8,300 for healthcare last year as well. The second-highest-spending country was Switzerland, paying about $8,009 per person. 

According to the research, the highest healthcare spending in the U.S. came from labor, prescription drugs and administrative costs. (Business Insider)

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To build scale and drive greater savings, providers in some regions are banding together in statewide Medicare accountable care organizations. 

CMS issued updated Medicaid guidance on regulations for state-run home and community-based services.

Regulators warn that suggestions to address surprise bills, such as rate setting and payment caps, come with significant downsides for states.