Payers Category

Posted On July 19, 2017By JUCMIn Payers

E/M Coding Could Be Heading for an Overhaul

The Centers for Medicare and Medicaid Services says providers have been clamoring for an update of the 1995 and 1997 guidelines for evaluation-and-management (E/M) codes—and it may be ready to oblige them. If it goes forward, the plan would take years to implement and focus mainly on revising the history and physical exam portion of a patient encounter. The aim, according to CMS, would be to simplify and better align E/M coding and documentation, presuming that would improve workflow at the practice level—including in urgent care centers. The changes wouldRead More
Hospital-owned urgent care centers—many of which became “hospital-owned” thanks to a relatively generous 50% reimbursement rate for off-campus patient visits—may be taking a substantial hit if the Centers for Medicare and Medicaid Services follows through on a plan to cut that rate by half. Hospital administrators say even though running off-campus clinics increases their operating budgets, they enable health systems to offer more patients access to cost-effective care. On the other hand, the Trump administration predicts cutting the pay rate to 25% could save the system as much as $25Read More
Trustees for the actual Medicare trust fund say it will be insolvent by 2029, a year later than predicted by the Obama administration last year. The year before that, the Congressional Budget Office foresaw the program running dry in 2026. This means the infamous Independent Payment Advisory Board—devised by the designers of the Affordable Care Act (ACA, or “Obamacare”) to put the brakes on Medicare spending if costs grew faster than a predetermined rate—will not take effect. The date by which Medicare would go out of business, so to speak,Read More
Centers for Medicare & Medicaid Services has broadened the definition of “small providers” as it applies to the Medicare Access and CHIP Reauthorization Act of 2015, to the extent that physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempt from having to comply with MACRA. Between this new standard and the one proposed for next year, the move will exclude roughly 834,000 more clinicians from complying with the quality reporting program under MACRA. (Originally, the limits were $30,000Read More
The Affordable Care Act—also known as the ACA, or “Obamacare”—famously drove many insurers out of state exchanges due to the difficulty they had in turning a profit through their participation. President Trump says the plan he’d like to see in place would be both superior and less expensive than his predecessor’s. Humana isn’t planning on sticking around to find out, however, and has announced it will not be participating in any individual insurance market after it exits ACA plans later this year. The company says the essence of participating inRead More
The Centers for Medicare and Medicaid Services’ plan to transition from a Social Security number-based ID system to a randomly generated identifier is moving forward. The agency won’t start mailing new cards until April 2018, and the whole process will take nearly 2 years to complete, but in the meantime CMS is rolling out a provider- and patient-awareness campaign to assure the transition is as smooth as possible. The new Medicare beneficiary identifier (MBI) will be the only patient ID recognized after the transition is complete in April 2019. TheRead More
Going to the emergency room for a simple sore throat will cost Georgians who get their insurance through Blue Cross Blue Shield of Georgia as of July 1, when a new rule designed to cut unnecessary healthcare costs goes into effect. In a nutshell, it demands that patients choose another care setting unless they have a true emergency—urgent care being the most likely source, given the difficulty many find when trying to make timely appointments with their primary care physician. If they do go to the emergency room with aRead More
Aetna has apparently had enough of trying in vain to make participation in Affordable Care Act (ACA, or “Obamacare) exchanges profitable, and will exit all ACA exchanges for the 2018 coverage year. They follow a long line of insurers who already checked out, complaining that the ACA program simply made it impossible to conduct business, economically.  Aetna announced their plans right after revealing that they’d drastically reduce their exchange business for the 2017 coverage year, selling plans only in Delaware, Iowa, Nebraska, and Virginia this year. Aetna will become theRead More
Missourians who still haven’t gotten the message that the emergency room is the wrong place to be for a sore throat or other nonemergent complaints are in for a rude awakening if they’re covered by Anthem. Starting this summer, Anthem will stop paying a dime for visits to Missouri EDs if the patient is deemed to have a “minor ailment” (which, in addition to sore throat, includes, rash, mild fever, and ear or eye pain—anything that can be treated safely in a “less acute” setting). There are a few exceptionsRead More
Illinois is not unique in wrestling with Medicaid managed care plan problems, but the situation there seems to have reached a boiling point and can serve as a cautionary tale for urgent care stakeholders across the country. Health system officials there complain that getting providers approved by Medicaid managed care plans has taken anywhere from 6 months up to a whole year. Prior authorizations and reimbursements have been similarly slow in coming, making it so cumbersome to do business that some have quit dealing with the state Medicaid system altogether.Read More