Payers Category

Posted On February 13, 2018By JUCMIn News, Payers

Anthem ED Policy is Starting to Rankle Patients

When Anthem announced some months ago it would not cover bills for “unnecessary” (in their retrospective view) trips to the emergency room in some states, we noted objections from physician groups. Now that the policy is in place and claims for 2018 have started to be filed, we’re seeing media reports on angry patients who are getting stuck with bills they presumed would be covered. Consumer Reports, for one, recounts the case of a patient who went to the ED because she thought she could be having a stroke. HerRead More
Physicians and patients alike have been vocal in their disapproval of Anthem’s policy of denying claims for emergency room visits that are ultimately declared nonemergent—the main criticisms being that it forces patients to self-diagnosis to some extent and that it ultimately may discourage patients from getting emergency care when they really do need it. Now the Indianapolis Recorder newspaper charges the policy is going to have the greatest negative impact on low-income patients, based on the presumption that urgent care centers tend to be more plentiful in higher-income communities. Anthem’sRead More
It was a long time coming, but as of January 1 patients covered by Tricare Prime can now visit any in-network urgent care center they want without a referral. The pilot program Congress instituted in May 2016 has become policy, doing away with restrictions that limited urgent care visits to two per year without receiving a referral. Point-of-service charges no longer apply, either. Tricare notes that the referral policy could be reinstated for 2019, and that the new policy does not apply to active-duty troops. In addition to those personnel,Read More

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