Monthly Archives: June 2016

Oscar Health Posted Losses in 2015 and 2016: The Realities of Being a Payer

Oscar Health launched with much fanfare and a great deal of Wall Street hype and being dubbed as the new way of being a health insurance company.  As its recent losses have shown, some of their major assumptions have not yet been realized. These include the move away from traditional employer-sponsored health insurance and thus more individuals shopping for health insurance on state and federal exchanges; controlling costs by tightly controlling provider networks; and positioning themselves to members as being consumer-focused, much like going to the Genius Bar at Apple stores to get iPhone issues resolved quickly and without much hassle.

Read more here.

As the ACA Matures, MD Exchange Co-op Sues Over Premium Risk Adjustment Calculation Issue

One of the major tenets of the ACA is to adjust premiums based on the overall health of the member; if a member is sicker than expected therefore costing the insurer more in claims experience, the payer will receive additional premium dollars.  However, if the member is relatively healthy, the insurer must pay back some premiums.  A MD-based co-op is suing the federal government over this program.

Read more here.

VA Choice: Not Such a Quick Fix to the Problems w/the VA Healthcare System

Many of us remember the uproar regarding the impossibly long waits veterans were having to endure in order to get a doctor’s visit w/in the VA health system.  This cost the top VA official his job in Washington.  But 90 days to implement access to private healthcare doctors and facilities is proving to be a challenge, too.

Read more  here.

Ouch! FL and Feds Owe $433 Million to Medicaid MCOs for Underpaying Premiums Over Two Years

I don’t know about you but I would have a reaction of sheer terror if I were told that I suddenly owed $433 million due to an error in classifying Medicaid eligible members over two years.  That is what the State of Florida and the federal government now face.

This is strange to me because a lot of Medicaid MCOs do extensive analysis in preparation for premium rating season where negotiations w/the State Medicaid Agency occur.  the MCO typically will analyze member’s claims experiences including diagnosis codes to determine the spend and severity of each category of member premiums.

I’d hate to be that person who was responsible for that.