Payers Category

Posted On November 14, 2017By JUCMIn Payers

North Carolina Blues Dial Up Telehealth Offerings

Blue Cross and Blue Shield of North Carolina is collaborating with MDLive to put more patients in touch with providers using remote hookups via an MDLive app, with an average wait time of less than 10 minutes. The insurer says it recognizes “the potential of telehealth to help providers deliver their services in a more cost-efficient setting…and facilitate value-driven care for patients.” That level of access is especially important in areas where ill patients would have to travel excessive distances to see a provider in person. Members with health plans withRead More

Posted On October 25, 2017By JUCMIn Payers

An Update on MIPS Readiness

If you read this newsletter and JUCM, you know the Merit-based Incentive Payment Systems (MIPS) offers a few options in an attempt to encourage participation and allow providers, essentially, to customize their participation to suit their practice. That includes when they start participating, within some limits. And if you read any news sources at all, you know there are more than a few wrinkles in the rollout. With that in mind, here are a few highlights that may be most applicable to the urgent care clinician and operators: Both 90-dayRead More
UnitedHealthcare Commercial in New Jersey and UnitedHealthcare Oxford of New Jersey will stop reimbursement of HCPC code S9083 as of January 1, 2018, according to a letter sent to providers. Instead, the plans are advising providers to “only report the evaluation and management and/or procedure code(s) that specifically describe the service(s) performed.”  S9083, they say, is “informational” and relates to a type of reimbursement rather than a specific service. Charges billed for S9083 will be denied once the policy takes effect. They will continue to reimburse providers for all servicesRead More
Cigna has announced that it will no longer cover prescriptions for the opioid medication OxyContin, and is recommending that patients who take it confer with their doctors to find an alternate pain drug. Cigna will, however, cover the alternative opioid drug Xtampza ER. The company says the move is in line with its “focus on helping customers get the most value from their medications”—which in this case extends to “obtaining effective pain relief while also guarding against opioid misuse.” Patients in hospice care or who are receiving cancer treatment areRead More

Posted On August 21, 2017By JUCMIn Payers

CMS Ups Its Game in Going After Medicare Fraud

Recent headlines have put Medicare fraud—and the search for those committing it—in the spotlight. However, urgent care clinicians who toe the line in treating Medicare patients are less likely to face unwarranted audits in the future—while fraudsters are putting themselves more at risk than ever—under a new system revealed by the Centers for Medicare and Medicaid Services (CMS). The agency is essentially narrowing the scope of practices it will investigate for fraud, hoping it will net a higher percentage of success than its current shotgun approach. The new process, calledRead More
We’ve told you recently about plans some insurers have to stick patients with the bill for emergency room visits that are retrospectively determined to have been nonemergent in nature. In essence, if patients go to the ED with an illness or injury that could have been handled in a lower-acuity setting (such as an urgent care center), as determined by the insurer, the patient’s claim will be denied. Now the American Medical Association is demanding that Anthem Blue Cross Blue Shield, for one, rescind that policy immediately in states whereRead More
Cigna is collaborating with CVS Health to push members into retail clinics instead of visiting urgent care centers when they have immediate, nonemergent medical needs. The company claims that around 45% of urgent care visits could be handled in drugstore clinics—at a savings of 81% per visit for Cigna. The problem? Cigna’s data highlight the minority of patients seeking care. The majority (55%) could not be treated sufficiently in the retail setting, meaning they’d end up having to go to at least two locations to get the appropriate care ifRead More
UnitedHealth Group Inc. was very open in its claims that it was impossible to sustain the economics of participating in healthcare exchanges under the Affordable Care Act (ACA, or “Obamacare”)—and thus the company would stop participating. It made good on that vow, and has now reported profit growth in the second quarter and raised its projections for the year, fueled by its Optum health-services arm. The largest insurer in the U.S. UnitedHealth has almost completely exited the ACA marketplaces. So far this year, the company’s net margin has risen toRead More

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