The CMS is probing whether providers and organizations are steering Medicare- or Medicaid-eligible patients toward the Affordable Care Act's insurance exchanges to receive higher reimbursement rates.
The move appears to be a response to complaints from insurers that some companies and patient-support groups are undermining the risk pool in the exchanges by subsidizing premiums for high-cost patients who should be covered by another government program.
The CMS released a request for information last week and sent letters to dialysis facilities about the action.
“We are concerned about reports that some organizations may be engaging in enrollment activities that put their profit margins ahead of their patients' needs,” acting CMS Administrator Andy Slavitt said in a statement. “These actions can limit benefits for those who need them, potentially result in greater costs to patients, and ultimately increase the cost of marketplace coverage for everyone.”
UnitedHealth Group, which is all but withdrawing from the ACA marketplaces next year, filed a lawsuit accusing American Renal Associates of illegally funneling money through a not-for-profit patient assistance group to pay insurance premiums for patients.
Last week, Aetna likewise said it would drastically scale back participation the ACA marketplaces. Weeks earlier, Aetna CEO Mark Bertolini alluded to specialty pharmacy costs driven by “third parties paying premiums for special interest groups” as a factor in the company's $300 million loss on ACA plans.
The CMS is considering limiting or prohibiting the payment of premiums and cost-sharing by third parties, as well as limiting provider payments Medicare-based amounts for certain services and items. The agency could also issue monetary penalties for people who fail to provide correct information about a plan.
