#medicare

Any more coming this way?

we’ve been told in the utilization review department in Medicare that we have too much staff but that’s OK because we’re all going to be trained on epic so too much staff right now is a good thing for coverage. That sounds like we will have layoffs of all the extra staff after epic is put in.really hoping they’ll be an early retirement package offer. Does anyone have any news?

INTEGRIS Health is implementing workforce reductions and closing several clinics. These actions are a direct response to anticipated significant cuts in Medicaid and Medicare funding. The organization expects an annual revenue loss of approximately $130 million once the new legislation is fully enacted. These changes will occur over the next three to six months. INTEGRIS Health stated these steps are necessary to ensure its long-term sustainability and mission.

Oklahoma City, Oklahoma

https://okcfox.com/news/local/integris-health-announces-layoffs-clinic-closures

https://finance.yahoo.com/healthcare/articles/health-insurers-dropping-medicare-advantage-100000446.html

Thousands of seniors are receiving notification that their Medicare Advantage plan won't be available next year, and there's nothing they can do about it except find another option.
One in 10 Medicare Advantage policyholders face forced disenrollment this year, according to an analysis by researchers at the Johns Hopkins Bloomberg School of Public Health. That's as many as 2.9 million Americans.

Humana's most severe legal and ethical controversies involve systemic denial of patient care using flawed predictive algorithms and major Medicare fraud settlements. Critics and lawsuits target its utilization of automated tools to prematurely cut off necessary rehabilitation and nursing care for elderly patients, alongside multi-million dollar federal fraud recoveries.

Systematic Care Denials via Algorithms

• The nH Predict Tool: Humana faced major class-action lawsuits for using an algorithmic model called nH Predict (developed by NaviHealth) to systematically forecast and cut off coverage for post-acute rehabilitation and skilled nursing facility care.
• Impact on Patients: Lawsuits allege the algorithm superseded individual doctor evaluations, leading to wrongful, repetitive denials of medically necessary care for vulnerable seniors who were forced to pay out-of-pocket or forego treatment.

Medicare and Billing Fraud Settlements

• Part D Bid Fraud ($90 Million Settlement): Humana paid $90 million to resolve a landmark whistleblower lawsuit brought by a former actuary. The suit accused Humana of keeping two sets of books and submitting fraudulent, inflated bids to the Centers for Medicare & Medicaid Services (CMS) for prescription dr-g contracts from 2011 to 2017.
• Overcharging Federal Audits: Federal audits by the Office of Inspector General (OIG) have repeatedly caught Humana overcharging Medicare by tens to hundreds of millions of dollars through unsupported risk-adjustment diagnoses.

Think this is getting added to the TriZetto algorithm? 😂

Centene denied 15% of standard Medicare Advantage prior auth requests in 2025.

Then 93% of the denials that were appealed got overturned.

But it was “one person at a time.” 😬

Centene also had the highest ACA denial rate listed at 25%.

Hard not to look at numbers like that and wonder whether the system is designed to get the right answer the first time, or just make people fight hard enough to get there.

Maybe the next efficiency initiative is getting rid of the members who keep appealing. 🤡

https://www.beckershospitalreview.com/finance/payers-ranked-by-prior-authorization-denial-rates/

Go to morningstar.com. There’s an article about it.

Heard WC got hit today. do we know if departments are notified all in one day? What exactly was the fallout

I’ve heard a lot of Marketplace but not Medicare.

In huddle this week, our PL said our debt SHOULD be safe. Anybody else in UM for Medicare hear the same? She briefly brushed past it so it didn’t seem super confident. Not sure if I should be happy or maybe we’re just safe FOR NOW. 😭

UCare is laying off more than 100 employees this fall. This action follows the company's decision to end its Medicare Advantage contracts. UCare plans to shift its members to a different organization. The terminations will begin on October 1st. This move is part of a larger transition for the health plan.

Minneapolis, Minnesota

https://www.kare11.com/article/news/local/ucare-announces-layoffs-for-100-positions/89-f36222ef-5707-4235-ae2b-8ef46ee8f031

Via Benefits is leaving messages that Wells Fargo authorized them to call me about Medicare. I did search and found them to be some sort of insurance advisory company. Before I call them back, does anyone have any experience with Via Benefits? Seems fishy, lots of companies want to “help” us Senior folks with Medicare.

Maybe they have a free knee brace offer that has a stage coach logo?!

President Trump is ending Medicare D subsidies at the end of the year. What happens then? It’ll push the largest Medicare D population to Medicare Advantage - the national product.

I got surplused 7/31, meet the MR75 and am eligible for Medicare. Retirees can sign up for company sponsored Medicare advantage PPO with $150 deductible and $900 out of pocket max for free. Seems like a great deal. Anybody else doing it, or are there other, better plans out there?

Centene started with layoffs in 2021 after acquiring WellCare, due to promising most of WellCare employees to keep there jobs. When Centene decided to rebrand their Medicare product (AllWell) to WellCare a decline started. After acquiring WellCare, members talked to people all over the USA, not just in the state they lived, this also caused a decline on membership. Cut the fat at the top, let the company go back to the way it was ( talk to people in your state that know your state and resources). Centene was a great company to work for until 2021, acquiring WellCare.
These are my thoughts and observations!

https://share.newsbreak.com/j6gnzs7h?s=i16

https://share.newsbreak.com/j6gnzs7h?s=i16

My PL informed us today that two members of our team (PDM in a Medicare market covering two states) took the VSP. Don't know who yet, but I'd imagine that info is coming soon. I'd say we have a fairly small team; eleven, counting me and our PL. What do you all think are the chances of more people getting axed when the layoffs begin? Prior to the last "reorganization," the team was only one state with six people counting me/PL, but we merged with another at that time. From what I've read here, there are some big ops-related changes re: Medicare coming, but I've not heard anything official yet.

Over on the Centene Health Insurance Layoff site, they said Centene just announced that they are offshoring Medicare business.

I wonder if the same will happen here at Humana.

I wonder what kind of malarkey the CFO & CEO are putting together to make Humana look so good. Wonder if they will say anything about all the qualified and experienced workers they are displacing.

Humana, and all of these large for-profit health insurance corporations, need to have their Medicare & Medicaid contracts taken away by the government. These corporations have milked and taken advantage of a system that has propped up these corporations that are not only fulfilling their end of the bargain.

The whole reason for these cooperations administering Medicare Advantage, in lieu of Traditional Medicare was to help keep costs from getting out of hand by guarding against fraud, waste, and abuse. But instead of fulfilling THAT mandate, these corporations are lining c-suite executives and shareholder’s pockets with millions of dollars, all the while in denying catastrophic health claims to the elderly, poor, and disabled AND displacing its own American citizen workforce with cheaper temporary H-1B Visas. And these corporations are not even dealing with the fraud, waste, and abuse. But they are denying legitimate claims.

These for-profit corporations would not even exist if not propped up by American tax payer monies. And yet they continue to layoff their very own country’s (Americans) workers, some of which even served their country during wars. This is a slap in the face to this country!

All of these large for-profit health insurance corporations such as Humana, Cigna, Centene, Elevance, etc. really need to go under or have the government completely remove their contracts for administering Medicare & Medicaid and those contracts need to be granted to non-profit and not-for-profit companies.

Shareholders and large banking firms never should have gotten their greedy fingers into heath insurance, which is intended to be a lifesaving and quality of life industry for our elderly seniors (and also the poor and disabled), which are human-beings, our brothers and sisters, that deserve our love and respect.

To all my peeps who were treated with disloyalty by Humana and forced out, keep in mind open enrollment for Medicare Advantage plans is just around the corner, beginning October 15th.

So, be sure to give you best sales pitch on social media and to all your elderly friends to why Traditional Medicare is better and why they should switch over this year and drop Medicare Advantage.

Let’s face it, we all really knew Traditional Medicare was better, especially in regards to what health insurance should be most concerned with, which is covering a person in the unfortunate situation where they have a catastrophic health issue. Not about dental or vision appointments.

The main problem is that our government contracts public traded corporations such as the above mentioned to take tax payer government funds and allow these companies to make administrative decisions on what claims get paid or not. The main issue with that is these are profit-based corporations required to put shareholders profits before members. The Medicare & Medicaid Members are secondary to them in regards to being their customer. The shareholders are their priority customer.

It is time for the government to drop these public stock traded health insurance corporations and find a way to contract with not-for-profit, non-public-stock-traded, companies to administer Medicare Advantage and Medicaid.

https://www.beckerspayer.com/workforce/elevance-sues-former-chief-execution-officer-over-noncompete-agreement/

Elevance Health is suing a former senior executive, alleging he violated a noncompete agreement when he joined Medicare Advantage insurer Alignment Healthcare weeks after resigning.

The complaint was filed June 5 in an Indiana federal court and names Shane Hochradel, who previously served in a variety of executive roles at Elevance starting in 2021, most recently as chief execution officer. Mr. Hochradel notified Elevance of his resignation on May 8 and started June 1 as COO at Alignment.

Elevance argues Alignment is a direct competitor in the Medicare Advantage market, with both insurers operating plans in Arizona, California, Nevada and Texas. Mr. Hochradel’s employment and stock award agreements barred him from taking a competing position for 12 months after his departure, according to the complaint. Elevance says that as chief execution officer, he led the company’s transformation team and helped develop a three-year plan to use artificial intelligence to cut costs and compete against rivals, including Alignment. Elevance alleges he cannot do his new job without drawing on that knowledge.

“Hochradel inevitably will use Elevance Health’s confidential information in his executive-level position at Alignment,” the complaint states.

Elevance also claims Mr. Hochradel did not notify its chief human resources officer that he was in talks with Alignment until after he accepted the role, a step his stock agreements required. The company said it learned of his new role on May 11 and reminded him of his contractual obligations, then informed Alignment of those obligations the following day.

Elevance is seeking compensatory damages and repayment of stock gains tied to equity that Mr. Hochradel exercised or vested over the prior 24 months, plus attorneys’ fees and costs. The suit is at least the fourth Elevance has brought against departing executives over noncompete agreements in recent years. In January, the company sued four former leaders at its Puerto Rico subsidiary who left for rival insurer Triple-S Salud, seeking more than $1.08 million in combined stock repayments. In September, it sued a former senior underwriting executive who joined health benefits company Gravie. And in 2023, Elevance sued its former west region Medicare president after she left for Molina Healthcare. A judge declined to block that move and the case was later settled.

At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration.

Presbyterian Healthcare Services announced 150 layoffs. These layoffs affect administrative roles. The affected positions are not in hospitals or clinics. The organization will also discontinue most Medicare Advantage plans in 2027. Direct patient care roles will remain unaffected.

Albuquerque, New Mexico

https://www.koat.com/article/presbyterian-layoffs-albuquerque-new-mexico/71475392

I just realized I have 15 years until I can get Medicare. I don’t know how I’m going to last that long. Every day at WF is miserable and there are no jobs out there to go to.

https://www.statnews.com/2026/04/30/elevance-health-fraud-doj-says-access-blocked-key-witness/

Is the medical benefit worth much? I see retirees complaining about it being cr-p and they just go with a paid Obamacare option instead. Maybe not worth sticking around for?

Layoffs and all the nonsense narratives that are spewed on this site have NOTHING to do with stock price. It's all about Medicare reimbursements, gov regulations and to a very small degree public sentiment. A huge amount of our stock is owned by massive mutual fund managers who KNOW it's significantly undervalued. The stock had a perfect storm last year of leadership instability and the gov coming after big insurance. Face it, the mu---r of Brian started a horrific downturn for the company which was roaring at the time. Then public sentiment and government tanked it.
Letting Gl 26's to GL 32's go and hiring offshore doesn't move the scale one bit. Sorry but that narrative is immature and un-insightful.
And ANYONE here who who says they want the company to fail isn't someone who has a career goal or isn't an employee at all.
Now throw all your shade and down arrows at me and call me a boomer but the truth is the truth.

Has anyone else noticed the recent increase in VTO offerings across Medicare/Medicaid member services?

Trying to better understand if this is just volume-related or part of a larger shift. If anyone has any general insight or perspective, it would be helpful.

Always good to stay aware of what’s going on.

When will it end?

A new report released by the bipartisan Senate Joint Economic Committee (JEC) on Tuesday found that overpaying for Medicare Advantage (MA) plans caused Medicare Part B premiums to rise across the board.

According to the JEC’s report, overpayments to MA plans caused standard monthly Medicare Part B premiums to go from $185 in 2025 to $203 in 2026.

The report defined “overpayments” as the difference between what the federal government government paid for MA plans versus Traditional Medicare (TM) plans. When payments to MA plans exceeds those for TM plans, premiums go up for both groups.

In 2025, MA plans were paid $84 billion more than it would have cost to cover the same amount of beneficiaries with TM plans, an average of 120 percent more.

Medicare Part B covers medically necessary services like doctors visits, supplies and some outpatient prescriptions as well as preventive services. Roughly 63 million people are enrolled in Medicare Part B and a little more than half are on Medicare Advantage, which combines both Part A and Part B.
The JEC further noted that the burden of MA overpayments are spread unevenly across the country as some districts and states have lower rates of MA enrollment. The report gave the example of Wyoming, where only 21 percent of Medicare beneficiaries are enrolled in MA, estimating that payers in the state will pay $25.4 million in excess premiums, with most of that from TM enrollees.

“Let’s be honest about the math, when Medicare Advantage is overpaid, that money doesn’t just disappear, it shows up in the Medicare Part B premiums seniors pay every month, including those paid by traditional Medicare beneficiaries who are not getting extra benefits,” said JEC Chair David Schweikert (R-Ariz.) said in a statement.

“If Congress is serious about affordability, fiscal responsibility, and fairness, we must take a hard look at Medicare Advantage and make sure the rules are the same for everyone,” he continued.

“Today, between aggressive upcoding, questionable quality bonuses, and structural overpayments in Medicare Advantage, seniors who stay in traditional Medicare are effectively subsidizing the system. That’s not sustainable, it’s not fair, and it can be reformed.”

What are the chances CMS will move off their proposed 0.09% rate for 2027?
It was approximately 5.0% for 2026 but they decided to basically eliminate it for 2027. After they announced the rate all health insurance stocks dropped massively.

Does anyone know anything about Medicaid or Medicare centralization work?

Happening in Medicare

Just had a talk with my adviser about this whole voluntary layoff thing….With me I am so close to 65, I plan to get out of telecomm and pick up a mediocre part time job to cushion the loss of CC funds. Come to find out the upcoming deposit of my severance, any upcoming bonus, banked PTO, etc etc….will be held against me when I start my Medicare…the large deposit will be a IRMAA surcharge on both my Medicare part B and part D premiums. This sliding scale of 5 brackets will no doubly kick my Medicare premiums a few more hundred dollars per month. To those of my coworkers who plan to jump into retirement after the severance comes may take this into consideration. If anyone has any constructive criticism on this matter, I’m all ears.

They say you can apply within 30 days to Medicare after your termination. Does anybody know when actually Medicare enrollment starts? In 2 month? January 1? Or when?

All health insurers are not doing great currently. Quickly look at their profit margin for the past 2-3 years and it’ll often be low single digit or negative

Medicare advantage is going to be tough again this year, so, not surprised

For those who were laid off — especially in Medicare/Medicaid Member Services (Community & State):

Looking back now, what were the real signs you were about to be laid off?

Not rumors. Not assumptions.
Actual changes you noticed in hindsight — workload shifts, meetings, metrics, access changes, team restructuring, communication patterns, etc.

I’m not asking to stir fear or spread speculation. I’m asking so those of us still here can be informed, prepared, and realistic.

If you’re willing to share, I’d appreciate it. Facts matter.

Honest question for those who were laid off (especially Medicare/Medicaid – Community & State, Member Services):

Before it happened, what were the signs you ignored or didn’t recognize at the time?

What changed first?

I’m not looking for reassurance. I’m looking for patterns.