Payers Category

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
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