Bloomberg - By John Tozzi- September 26, 2018, 9:01 PM PDT A new federal watchdog report warns that privately run Medicare health plans used by millions of older Americans may be improperly denying patients medical care. Federal auditors have found “widespread and persistent problems related to denials of care and payment in Medicare Advantage,” the privately administered plans that insure more than 20 million people, according to the report from the Health and Human Services Office of Inspector General. Medicare Advantage plans collect a fixed fee from the government for taking care of patients 65 or older who qualify for traditional Medicare coverage. The fixed per-patient rates the government pays may give plans “an incentive to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits,” the report said. Medicare Advantage plans have become popular with consumers because they combine traditional Medicare benefits with additional coverage, such as vision, dental care, and prescription drugs. The program paid $210 billion to Medicare Advantage plans last year. Companies including UnitedHealth Group Inc., Humana Inc., and Aetna Inc. are the largest sellers of the coverage. Enrollment in Medicare Advantage has roughly doubled in the past decade, and one-third of Medicare patients are now covered by the private plans. In 2016, Medicare Advantage plans denied 4 percent of requests to approve treatment before it was provided, known as prior authorization, and 8 percent of requests for payment after treatment, according to the report. Only 1 percent of patients disputed the insurers’ denials, but in those cases, the decisions were overturned three-quarters of the time, according to the report. Improper denials “may contribute to physical harm for beneficiaries if they’re not getting access to services that they [...]
Permalink GalleryBlog, Commercial Insurance, Credentialing, Doctor, doctor, doctor Credentialing, Health Insurance, Healthcare Changes, Healthcare Professionals, ICD-10, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing, Verification
Benefits PRO - Susan Jaffe | September 19, 2018 at 11:07 AM Under the new rules, private Medicare insurance plans could require patients to try cheaper drugs before moving on to more expensive options. Starting next year, Medicare Advantage plans will be able to add restrictions on expensive, injectable drugs administered by doctors to treat cancer, rheumatoid arthritis, macular degeneration and other serious diseases. Under the new rules, these private Medicare insurance plans could require patients to try cheaper drugs first. If those are not effective, then the patients could receive the more expensive medication prescribed by their doctors. Related: Government drug price disclosure confirms it: costs are soaring Insurers use such “step therapy” to control drug costs in the employer-based insurance market as well as in Medicare’s stand-alone Part D prescription drug benefit, which generally covers medicine purchased at retail pharmacies or through the mail. The new option allows Advantage plans — an alternative to traditional, government-run Medicare — to extend that cost-control strategy to these physician-administered drugs. In traditional Medicare, which covers 40 million older or disabled adults, those medications given by doctors are covered under Medicare Part B, which includes outpatient services, and step therapy is not allowed. About 20 million people have private Medicare Advantage policies, which include coverage for Part D and Part B medications. Some physicians and patient advocates are concerned that the pursuit of lower Part B drug prices could endanger very sick Medicare Advantage patients if they can’t be treated promptly with the medicine that was their doctor’s first choice. Critics of the new policy, part of the administration’s efforts to fulfill President Donald Trump’s promise to cut drug prices, say it lacks some crucial details, including how [...]
Healthcare Finance -Susan Morse Senior Editor - September 10, 2018 Ruling throws out 2014 rule, leading to question of how CMS will determine whether it has overpaid an MA insurer. UnitedHealthcare wins court case over Medicare Advantage overpayment rule Ruling throws out 2014 rule, leading to question of how CMS will determine whether it has overpaid an MA insurer. UnitedHealthcare has won its court case over the way the Centers for Medicare and Medicaid Services calculates whether it has overpaid Medicare Advantage insurers. The U.S. District Court for the District of Columbia on Friday granted UnitedHealth's motion for summary judgement and vacated CMS's 2014 overpayment rule, leading to the question of how CMS will amend the rule to determine whether it has overpaid an MA insurer. CMS could also appeal the ruling. Federal Judge Rosemary Collyer said the 2014 overpayment rule was not equitable to Medicare and Medicare Advantage insurers, which is required by law. One of the issues for insurers is that the current way CMS calculates payment results in the false appearance of better health among Medicare Advantage enrollees compared to traditional Medicare participants, leading to systematic underpayments to MA insurers, according to the ruling. Judge Collyer said the current way CMS calculates payment subjects the insurers to a more searching form of scrutiny than CMS applies to its own enrollee data, resulting in a false appearance of better health among Medicare Advantage beneficiaries. Medicare pays hospitals based on the diagnosis related group, or DRG, at the time of patient discharge. Under Medicare Part B, physicians submit diagnosis codes, but payment depends on the services provided, and not on the way the diagnosis is submitted. In contrast, MA insurers are not paid based [...]
Come out and hear our owner Tia Aspra speak at 11th edition of Larry Laurent’s Chiropractic Law SeminarChiropractic, doctor, doctor Credentialing, Health Insurance, Healthcare Changes, Healthcare Professionals, Medical, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Multi-Specialty, Obamacare, Physician Credentialing, Specialties, Staff Training
Come out and hear our owner Tia Aspra speak at 11th edition of Larry Laurent’s Chiropractic Law Seminar
Come out and hear our owner Tia Aspra speak at 11th edition of Larry Laurent’s Chiropractic Law Seminar series on Saturday, September 8, 2018. This fall’s event will be held in Austin, at the Granduca Hotel – 320 South Capital of Texas Hwy, Bldg B, Austin, Texas, 78746 from 8:00 a.m. to approximately 5:30 p.m. Ms. Tia Aspra of Financial Investigation & Reimbursement Management and Ms. Kathy Jones of NACA - Texas, will be providing tips on risk management, coding, credentialing, documentation and office compliance practices to ensure that your new practice complies with all state and federal laws, as well as our Board’s regulatory programs. This Chiropractic Law seminar has been approved for 8 hours of CE credit, including the 4 hours of Ethics, Documentation and Jurisprudence required by the Texas Board of Chiropractic Examiners. We have kept the cost low - $198.00 for doctors, $79.00 for staff accompanying a doctor and $98 for CA/staff attending without a doctor. You will have the opportunity to obtain thousands of dollars worth of free legal information, consulting services and information on office procedures for a very low registration fee. To register give Larry Laurent a call at (512) 996-8844 or send an email to (firstname.lastname@example.org) if you have any questions. We hope to see you in Austin on Saturday, September 8, 2018.