{"id":13391,"date":"2024-11-04T14:34:47","date_gmt":"2024-11-04T14:34:47","guid":{"rendered":"https:\/\/distilinfo.com\/healthplan\/?p=13391"},"modified":"2024-11-04T14:34:47","modified_gmt":"2024-11-04T14:34:47","slug":"centene-plan-boosts-quality-services","status":"publish","type":"post","link":"https:\/\/distilinfo.com\/healthplan\/centene-plan-boosts-quality-services\/","title":{"rendered":"Centene Visionary Plan Boosts Quality in Healthcare Services"},"content":{"rendered":"\r\n<div id=\"rank-math-toc\" class=\"wp-block-rank-math-toc-block has-pale-ocean-gradient-background has-background\"><nav>\r\n<ul>\r\n<li><a href=\"#introduction\">Introduction<\/a><\/li>\r\n<li><a href=\"#centenes-star-rating-dispute\">Centene\u2019s Star Rating Dispute<\/a><\/li>\r\n<li><a href=\"#united-health-groups-settlement-with-the-u-s-department-of-labor\">UnitedHealth Group\u2019s Settlement with the U.S. Department of Labor<\/a><\/li>\r\n<li><a href=\"#humanas-lawsuit-over-2025-star-ratings\">Humana\u2019s Lawsuit Over 2025 Star Ratings<\/a><\/li>\r\n<li><a href=\"#regence-blue-shield-of-idaho-vs-blue-cross-of-idaho\">Regence BlueShield of Idaho vs. Blue Cross of Idaho<\/a><\/li>\r\n<li><a href=\"#blue-cross-blue-shield-associations-2-8-billion-settlement\">Blue Cross Blue Shield Association\u2019s $2.8 Billion Settlement<\/a><\/li>\r\n<li><a href=\"#l-a-cares-55-million-penalty\">L.A. Care\u2019s $55 Million Penalty<\/a><\/li>\r\n<li><a href=\"#aetnas-medicaid-contract-petition-denial-in-kansas\">Aetna\u2019s Medicaid Contract Petition Denial in Kansas<\/a><\/li>\r\n<li><a href=\"#united-healthcares-medicare-advantage-star-ratings-dispute\">UnitedHealthcare\u2019s Medicare Advantage Star Ratings Dispute<\/a><\/li>\r\n<li><a href=\"#conclusion\">Conclusion<\/a><\/li>\r\n<li><a href=\"#fa-qs\">FAQs<\/a>\r\n<ul>\r\n<li><a href=\"#q-1-why-are-star-ratings-important-for-healthcare-payers\">Q1: Why are star ratings important for healthcare payers?<\/a><\/li>\r\n<li><a href=\"#q-2-what-was-significant-about-the-bcbs-2-8-billion-settlement\">Q2: What was significant about the BCBS $2.8 billion settlement?<\/a><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/nav><\/div>\r\n\r\n\r\n\r\n<h2 id=\"introduction\" class=\"wp-block-heading\">Introduction<\/h2>\r\n\r\n\r\n\r\n<p>Legal challenges and settlements are a constant in the healthcare industry, especially for major payers who frequently navigate regulatory changes, antitrust issues, and disputes over contractual obligations. From star rating challenges to record-breaking settlements, recent lawsuits reveal ongoing tensions and regulatory scrutiny in payer practices.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"centenes-star-rating-dispute\" class=\"wp-block-heading\">Centene\u2019s Star Rating Dispute<\/h2>\r\n\r\n\r\n\r\n<p><strong>Centene Requests Recalculation of Star Rating<\/strong><\/p>\r\n\r\n\r\n\r\n<p>Centene, a leading healthcare payer, has requested that a federal judge mandate the<a href=\"https:\/\/www.healthcarefinancenews.com\/news\/centene-sues-cms-over-medicare-advantage-star-ratings\" target=\"_blank\" rel=\"noopener\"> Centers for Medicare &amp; Medicaid Services (CMS)<\/a> to recalculate its star rating. Centene argues that an alleged \u201csecret shopper\u201d phone call, which did not reach its call center, unfairly impacted its rating. Star ratings significantly influence payer reputations and affect reimbursement rates, making this case pivotal for Centene\u2019s market position.<\/p>\r\n\r\n\r\n\r\n<p><strong>Implications of Star Ratings in Healthcare<\/strong><\/p>\r\n\r\n\r\n\r\n<p>Star ratings directly impact patient perceptions, enrollment, and the overall financial performance of payers. Centene\u2019s case underscores the importance of fair assessment in the star rating process and how technical glitches or external evaluations could skew results.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"united-health-groups-settlement-with-the-u-s-department-of-labor\" class=\"wp-block-heading\">UnitedHealth Group\u2019s Settlement with the U.S. Department of Labor<\/h2>\r\n\r\n\r\n\r\n<p><strong>UnitedHealth Settles Over Denied Claims<\/strong><\/p>\r\n\r\n\r\n\r\n<p>UnitedHealth Group reached a settlement with the U.S. Department of Labor following allegations that it improperly denied claims related to emergency room visits and urinary drug screenings.<\/p>\r\n\r\n\r\n\r\n<p><strong>Regulatory Compliance in Claim Denials<\/strong><\/p>\r\n\r\n\r\n\r\n<p>The case highlights the ongoing issue of denied claims in healthcare and the importance of adhering to federal guidelines to prevent unlawful denials. UnitedHealth\u2019s settlement illustrates a commitment to resolving disputes and safeguarding patient rights.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"humanas-lawsuit-over-2025-star-ratings\" class=\"wp-block-heading\">Humana\u2019s Lawsuit Over 2025 Star Ratings<\/h2>\r\n\r\n\r\n\r\n<p><strong>Humana Seeks Recalculation of 2025 Star Ratings<\/strong><\/p>\r\n\r\n\r\n\r\n<p>Similar to Centene, Humana has filed a lawsuit demanding that CMS retract and recalculate its 2025 star ratings. The company claims inaccuracies in the ratings could affect its competitive stance and profitability. Humana&#8217;s lawsuit sheds light on the broader industry concern about transparency and accuracy in CMS\u2019s rating methodology.<\/p>\r\n\r\n\r\n\r\n<p><strong>Star Ratings and Competitive Market Position<\/strong><\/p>\r\n\r\n\r\n\r\n<p>With star ratings influencing consumer choices, payers are increasingly vigilant about how these ratings are determined. For Humana, securing an accurate rating is crucial to maintaining its competitive edge in the Medicare Advantage market.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"regence-blue-shield-of-idaho-vs-blue-cross-of-idaho\" class=\"wp-block-heading\">Regence BlueShield of Idaho vs. Blue Cross of Idaho<\/h2>\r\n\r\n\r\n\r\n<p><strong>Regence BlueShield Retains State Contract in Idaho<\/strong><\/p>\r\n\r\n\r\n\r\n<p>A state judge in <a href=\"https:\/\/idahocapitalsun.com\/2024\/07\/23\/idaho-switched-government-employee-health-insurers-now-lawsuit-seeks-to-void-1-1b-contract\/\" target=\"_blank\" rel=\"noopener\">Idaho<\/a> dismissed a lawsuit by Blue Cross of Idaho, allowing Regence BlueShield to remain as the state\u2019s health plan administrator. Blue Cross had contested the contract, seeking to invalidate it on various grounds.<\/p>\r\n\r\n\r\n\r\n<p><strong>Importance of State Contracts in Payer Market Dominance<\/strong><\/p>\r\n\r\n\r\n\r\n<p>Winning state contracts can lead to significant revenue and growth opportunities for payers, making these contracts highly contested. The Regence vs. Blue Cross case highlights the competitive nature of securing these lucrative agreements.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"blue-cross-blue-shield-associations-2-8-billion-settlement\" class=\"wp-block-heading\">Blue Cross Blue Shield Association\u2019s $2.8 Billion Settlement<\/h2>\r\n\r\n\r\n\r\n<p><strong>Record-Breaking Antitrust Settlement<\/strong><\/p>\r\n\r\n\r\n\r\n<p>The Blue Cross Blue Shield Association, along with 33 independent Blue Cross Blue Shield (BCBS) companies, agreed to pay $2.8 billion to settle antitrust claims brought by healthcare providers. This settlement, one of the largest in the industry, addresses claims that BCBS companies colluded to limit competition in certain markets.<\/p>\r\n\r\n\r\n\r\n<p><strong>Antitrust Laws in Healthcare<\/strong><\/p>\r\n\r\n\r\n\r\n<p>Antitrust settlements underscore the importance of fair competition within the healthcare industry. This historic case sends a message to other payers about the financial and reputational consequences of engaging in anti-competitive practices.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"l-a-cares-55-million-penalty\" class=\"wp-block-heading\">L.A. Care\u2019s $55 Million Penalty<\/h2>\r\n\r\n\r\n\r\n<p><strong>L.A. Care Fined for Improper Claims Denials<\/strong><\/p>\r\n\r\n\r\n\r\n<p>L.A. Care, a large health plan, has been penalized $55 million for improperly denying claims and accumulating a backlog of unresolved grievances. The fine is part of a broader push by regulators to ensure that health plans meet high standards of accountability and service.<\/p>\r\n\r\n\r\n\r\n<p><strong>Regulatory Oversight on Claim Processing<\/strong><\/p>\r\n\r\n\r\n\r\n<p>The penalty highlights the critical role of regulatory oversight in maintaining payer accountability. By enforcing penalties, regulators aim to improve claims processing standards and protect patient interests.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"aetnas-medicaid-contract-petition-denial-in-kansas\" class=\"wp-block-heading\">Aetna\u2019s Medicaid Contract Petition Denial in Kansas<\/h2>\r\n\r\n\r\n\r\n<p><strong>Kansas Judge Denies Aetna\u2019s Medicaid Petition<\/strong><\/p>\r\n\r\n\r\n\r\n<p>A Kansas judge recently denied Aetna\u2019s petition to review the state\u2019s Medicaid contract awards, which excluded the insurer. Aetna\u2019s challenge was part of its efforts to regain footing in the state\u2019s Medicaid program, but the court ruled in favor of the existing contract awardees.<\/p>\r\n\r\n\r\n\r\n<p><strong>Medicaid Contract Competitions<\/strong><\/p>\r\n\r\n\r\n\r\n<p>Securing Medicaid contracts can be highly competitive and financially rewarding for payers. Aetna\u2019s unsuccessful petition in Kansas illustrates the complexities and risks associated with bidding for these contracts.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"united-healthcares-medicare-advantage-star-ratings-dispute\" class=\"wp-block-heading\">UnitedHealthcare\u2019s Medicare Advantage Star Ratings Dispute<\/h2>\r\n\r\n\r\n\r\n<p><strong>UnitedHealthcare Seeks Relief Over Medicare Star Ratings<\/strong><\/p>\r\n\r\n\r\n\r\n<p>In a move similar to Centene and Humana, UnitedHealthcare is appealing to a federal court to prevent CMS from downgrading its Medicare Advantage star rating based on a single phone call evaluation. The payer argues that the downgrade could unfairly affect its standing in the Medicare Advantage market.Medicare Advantage Ratings and Market Impact<\/p>\r\n\r\n\r\n\r\n<p>For payers like UnitedHealthcare, star ratings directly impact reimbursement rates and customer acquisition. This case highlights the ongoing contention over CMS\u2019s rating criteria and the financial implications for Medicare Advantage providers.<\/p>\r\n\r\n\r\n\r\n<h2 id=\"conclusion\" class=\"wp-block-heading\">Conclusion<\/h2>\r\n\r\n\r\n\r\n<p>The recent wave of lawsuits and settlements among healthcare payers reflects a growing focus on regulatory compliance, fair competition, and accurate rating methodologies. These cases underscore the high stakes involved for payers in maintaining favorable reputations, securing key contracts, and adhering to regulatory standards. As legal disputes continue to shape the healthcare landscape, payers are expected to remain vigilant and proactive in mitigating potential legal challenges.<\/p>\r\n\r\n\r\n\r\n<p><span data-teams=\"true\"><span class=\"ui-provider a b c d e f g h i j k l m n o p q r s t u v w x y z ab ac ae af ag ah ai aj ak\" dir=\"ltr\">Discover the latest <a id=\"menurbs\" class=\"fui-Link ___1q1shib f2hkw1w f3rmtva f1ewtqcl fyind8e f1k6fduh f1w7gpdv fk6fouc fjoy568 figsok6 f1s184ao f1mk8lai fnbmjn9 f1o700av f13mvf36 f1cmlufx f9n3di6 f1ids18y f1tx3yz7 f1deo86v f1eh06m1 f1iescvh fhgqx19 f1olyrje f1p93eir f1nev41a f1h8hb77 f1lqvz6u f10aw75t fsle3fq f17ae5zn\" title=\"https:\/\/distilinfo.com\/healthplan\/\" href=\"https:\/\/distilinfo.com\/healthplan\/\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\"Link payers&#039; news updates\"><strong>payers&#8217; news updates<\/strong><\/a> with a single click. Follow <a id=\"menurbu\" class=\"fui-Link ___1q1shib f2hkw1w f3rmtva f1ewtqcl fyind8e f1k6fduh f1w7gpdv fk6fouc fjoy568 figsok6 f1s184ao f1mk8lai fnbmjn9 f1o700av f13mvf36 f1cmlufx f9n3di6 f1ids18y f1tx3yz7 f1deo86v f1eh06m1 f1iescvh fhgqx19 f1olyrje f1p93eir f1nev41a f1h8hb77 f1lqvz6u f10aw75t fsle3fq f17ae5zn\" title=\"https:\/\/distilinfo.com\/healthplan\/\" href=\"https:\/\/distilinfo.com\/healthplan\/\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\"Link DistilINFO HealthPlan\">DistilINFO HealthPlan<\/a> and stay ahead with updates on <strong>medical advancements<\/strong>. Join our community today!<\/span><\/span><\/p>\r\n\r\n\r\n\r\n<h2 id=\"fa-qs\" class=\"wp-block-heading\">FAQs<\/h2>\r\n\r\n\r\n\r\n<h3 id=\"q-1-why-are-star-ratings-important-for-healthcare-payers\" class=\"wp-block-heading\">Q1: Why are star ratings important for healthcare payers?<\/h3>\r\n\r\n\r\n\r\n<p>Ans: Star ratings influence a payer\u2019s reimbursement rates, consumer trust, and market position. Accurate ratings are crucial for competitiveness.<\/p>\r\n\r\n\r\n\r\n<h3 id=\"q-2-what-was-significant-about-the-bcbs-2-8-billion-settlement\" class=\"wp-block-heading\">Q2: What was significant about the BCBS $2.8 billion settlement?<\/h3>\r\n\r\n\r\n\r\n<p>Ans: The settlement resolved antitrust claims against BCBS, highlighting the importance of fair competition in the healthcare industry.<\/p>\r\n","protected":false},"excerpt":{"rendered":"<p>Introduction Legal challenges and settlements are a constant in the healthcare industry, especially for major payers who frequently navigate regulatory&#8230; <a href=\"https:\/\/distilinfo.com\/healthplan\/centene-plan-boosts-quality-services\/\" style=\"white-space: nowrap;\">Continue Reading <i class=\"fas fa-long-arrow-alt-right\" style=\"vertical-align: middle;\"><\/i><\/a><\/p>\n","protected":false},"author":1,"featured_media":13392,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[1],"tags":[88,178],"class_list":{"0":"post-13391","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-distilinfo-originals","8":"tag-centene","9":"tag-humana","10":"entry"},"_links":{"self":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13391"}],"collection":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/comments?post=13391"}],"version-history":[{"count":4,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13391\/revisions"}],"predecessor-version":[{"id":13425,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/posts\/13391\/revisions\/13425"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/media\/13392"}],"wp:attachment":[{"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/media?parent=13391"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/categories?post=13391"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/distilinfo.com\/healthplan\/wp-json\/wp\/v2\/tags?post=13391"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}