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Humana is the second largest medicare insurer in the country. But during the annual day of the company’s investors on Monday, Humana was defender No. 1 of the program.
During the four -hour event, Humana exercised a noisy defense of private medication plans, which are popular among the elderly, but face increasing calls for reform in the midst of evidence that the main insurers play the program to bend down.
It is misunderstood, Humana ‘leaders said. Its very unloved payment structure encourages insurers to better coordinate care, leading to better results. This saves money for the elderly and taxpayers, they said.
MA, in which the Government contracts private payers to manage care for Medicare’s elders, grew up to cover more than half of all members of the federal insurance regime. Historically, he appreciated large bipartisan support.
But the prospects for the privatized alternative of health insurance have embellished in recent years, as part of the growing attention of bad behavior in MA while the Republicans in Washington are looking to brake waste, fraud and abuse in federal programs.
However, MA is essentially untouchable because of its support for reliable senior voters, according to humana leaders.
And the concerns about the controversial practices of payers intended to prevent the selection of cherries from healthier members, the diagnostics of capture earlier and the control costs are exaggerated, explained the CEO of Humana, Jim Rechtin – however, it has allowed there to be ways to improve.
“Risk adjustment and home assessments and previous authorizations have become dirty words. And they should not be dirty words,” said Rechtin. “These are excellent clinical tools. And we will defend them all day … but we have to do it responsible.”
Protect the status quo – mainly
Humana, which covers 6 million members in MA, is important financial incentive to protect the program against major changes. Privatized Medicare Plans represented $ 24.1 billion in its $ 27.8 billion in total premiums last year.
But the insurer struggled to maintain the benefits in the midst of opposite winds in the program, including higher medical costs and unfavorable regulatory updates that rerived the reimbursement.
And the actions of the main payers of MA were down in the midst of a series of recent research and media reports that draw attention to the commercial practices of insurers who, according to criticism, delay excessively or refuse care to members and inflate the government’s payments by billions of dollars each year.
For example, the CMS will pay the insurers of my 84 billion dollars more this year than if these members had been in a traditional medication, according to the influential advisory group of the Medpac Congress. Many of these overpayers have been motivated by the UP coding, in which my payers’ game diagnostic codes to exaggerate the health needs of their members – seizing higher government payments along the way.
Home assessments, in which payers send me a nurse or another clinician to visit a patient at their home, are a problematic area. These visits generate billions of inflated income for my payers by allowing them to grasp more diagnoses, according to a survey by the Wall Street Journal on Medicare Advantage Practices.
Insurers say that home checks help them treat the elderly in a more practical and comfortable setting and identify all additional needs that could go unnoticed during a visit to the doctor.
“”We have talked a lot about these annual well-being visits may not be a good thing. This is not true. Our annual well-being visits, home visits are loved by our seniors, “said George Renaudin, Humana insurance president.
But eArmy this month, the WSJ reported that Humana supports new limits to the diagnostic payments recorded by nurses in home visits which are not supported by other patient files.
“What we are not going to invest dollars is to continue the diagnostic codes that do not lead the system to a better place,” said Rechtin.
Likewise, although the prior authorization is necessary to ensure that providers only give up to date and most relevant clinical care, “we know that the prior authorization process creates friction,” said Renaudin.
Renaudin said Humana “worked hard” to reduce this friction by removing codes that do not require Humana green lamp and the automation of previous authorization determinations.
Despite a full -courted press of insurers to prevent a significant reform, Washington regulators and legislators took note of the concerns about MA.
GOP leadership in the Senate has planned to weave the reform of the reform of the reform of the Republican reconciliation bill, according to reports. However, the senators recently submitted these comments – and, the preliminary text published by the Senate finance committee on Monday does not offer any change in Medicare.
Senators probably faced a political reality recognized during the Humana investor day.
“We live in this world which is in a way the unstoppable classical force which comes up against the irremovable object,” said Rechtin. “TThe unstoppable force is American budgetary pressures … aAnd the irremovable object are the elderly who vote. »»
“Elderly people have a voice in this country. And they love Medicare Advantage,” added the CEO.
Renaudin cited an investigation noting that 9 out of 10 voters with my considering the support of a major program candidate during the vote. And, more than half of the American congress districts have more than 50% of their elderly people in MA, according to the executive.
But the threat to MA’s comfortable status quo is not only the legisaltive branch, after the main health regulators of the Trump administration said they were interested in repressing the Codoscope to MA.
The CMS has announced this spring to increase the number of Plan MA payment audits and accelerate its revision backwards.
Renaudin refused to specifically comment on retroactive audits on Monday, citing the dispute that Humana filed against the process. But Humana already proactively removes the codes he determines is not supported by clinical documentation, said the insurance president.
As for the most recent push of CMS, “the challenge will be there in the new audit process,” said Renaudin. “However, it is really difficult to extrapolate what will be the impact of this when the complete methodology, exactly how they will try to respect these deadlines, is not so well known at this stage.”
Planning of the “Scenario of the worst case”
Humana’s investor day took place in Louisville, Kentucky, where the company has its registered office, instead of New York, where such conferences are generally held. Insurers are increasingly fighting the listening to public oriented events after the cheeky murder of Brian Thompson, CEO of Unitedhealthcare, in Manhattan at the end of last year.
During the day, Humana has updated investors on her efforts to improve the margins by 2028 – including by improving her star notes, quality measures that are inextricably linked to the reimbursement of the program.
Humana saw her average star note drop for 2025, which will lead the payer to lose $ 1 billion at $ 3 billion in 2026, according to industry data and analysts.
Although the insurer continued to reverse the changes at the end of last year, a federal court has not yet ruled on the case. In April, the company lost a separate adminsitrative call for the CMS.
During the investor conference, Rechtin said Humana provided that his activities lose this trial.
“”We have no new information, “said Rechtin.” We have to plan the worst case. “”
Despite recent improvements to her stars, Humana expects her not reaching the total points required for a four -star note before the 2028 bonus year.
“”[Humana’s] The operating hypothesis of a mixture of stars lower than the future seems cautious, “wrote Lisa Gill, analyst of JP Morgan, in a note on the day of payers’ investors.
Management reported that Humana’s revenues could decrease in 2026 due to the opposite winds of the stars. However, Humana does not expect to retreat the advantages in her plans in order to keep existing members.
Despite MA’s trembling status, Humana still continues the growth of Medicaid and its Centerwell health services division, the leaders said. Medicaid’s profits are expected to increase as the company ripens in the coming years, given the relatively recent expansion of Humana in the security program, managers said.
And Humana plans to buy more primary care practices to strengthen the organization of Centerwell primary care – even after acquiring more than 100 clinics in the past two years, Leadership said. Centerwell currently has more than 325 primary care centers.
But “IIt is not lost to us that the heart of our company is Medicare Advantage. When Medicare Advantage does not work, the rest of our commercial struggles. And we therefore need health insurance to work, ”said Rechtin.
