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Insurers Gobble Doctor Practices To Bolster Medicare Advantage Plans

Forbes- Bruce Japsen - MAR 12, 2018 @ 08:00 AM News that Centene is buying a large medical group is the latest sign that health insurers are engaged in a doctor-buying binge to compliment their Medicare Advantage businesses by owning group practices that treat a lot of seniors. In Centene’s case, the health insurer is getting a provider of medical care in Community Medical Group that has 15 health centers throughout the Miami-Dade County area of south Florida. Centene last week described Community Medical as a “leading at-risk primary care provider” that serves more than 70,000 patients including those covered by Medicare Advantage. It’s the kind of deal that insurers are scouting across the country. “There will be more acquisitions of primary care groups,” Bill Frack, a managing director in L.E.K Consulting ’s health care services practice said in an interview. “Sophisticated groups are the best way to manage the cost of care in an effective manner. They have the resources to manage complicated cases in a sophisticated way.” To be sure, health plans are on the hunt to buy doctor practices with the staff, technology, information systems and providers to effectively manage the complex care of elderly Medicare beneficiaries, particularly as value-based care takes hold. Practices that provide effective treatment upfront in the doctor’s office leave more of the premium dollar for an insurance company to profit from or share with the providers. The Centene deal surprised some observers given the insurer is better known for administering Medicaid benefits for states and offering individual coverage under the Affordable Care Act. In buying Community Medical, it will get a provider of medical care that has patients insured by all three forms of insurance: Medicaid, Obamacare [...]

What merger mania means for health care

CNN Money- by Paul R. La Monica- March 8, 2018: 12:32 PM ET Get ready for another wave of massive health care deals -- and maybe this time the government will approve them. Health insurer giant Cigna's proposed purchase of pharmacy benefits manager Express Scripts for $67 billion comes just three months after Cigna rival Aetna agreed to be bought by drugstore chain CVS (CVS) for $69 billion. The insurance companies have been forced to find alternative ways to adapt and grow in a rapidly changing health care industry after the Justice Department blocked two massive deals involving four of the five biggest health insurers on antitrust grounds a year ago. Cigna (CI) and Anthem (ANTM) called off their proposed combination in February 2017 -- and rivals Aetna (AET) and Humana (HUM) announced they were ending plans to merge on the same day. UnitedHealth (UNH) is the other major health care insurer. But the Cigna-Express Scripts and CVS-Aetna deals, in theory, have a better chance of getting approved by regulators since they are so-called vertical, as opposed to horizontal, mergers. In plain English, that means the mergers aren't ones where two similar companies are looking to combine and take a competitor out of the market. Instead, they're trying to add a new line of business. Still, the deal between Cigna and Express Scripts (ESRX) is yet another clear sign that the health care industry in America could soon be dominated by just a small handful of giant conglomerates. For example, the pharmacy benefits management industry, which negotiates with the big drug makers to try and get better prices on prescription medications for consumers, is already dominated by Express Scripts, CVS and UnitedHealth. If CVS gets approval to [...]

Google sister-company Verily is plotting a move into a fast-growing corner of the health insurance industry

CNBC -Christina Farr | @chrissyfarr -Updated 11:27 AM ET Tue, 27 Feb 2018 Verily's new hires and partnerships point to a move into health insurance. The company is looking to take on risk for patient populations and sharing in the upside if it can bring down health-care costs, sources tell CNBC. The opportunity is currently in the tens of billions, with the potential to grow into a trillion dollar market. Alphabet's health-care unit Verily is moving ahead with plans in the insurance sector with new hires and partnerships. Three people familiar with the company's plans say Verily, the group formerly known as Google Life Sciences, has been in talks with insurers about jointly bidding for contracts that would involve taking on risk for hundreds of thousands of patients. In 2016, it mulled jointly putting in a proposal with Alphabet-backed insurer Oscar Health to manage care for thousands of low-income Rhode Island residents on Medicaid, one of the sources said, but ultimately decided against it. Now, it is moving ahead with plans to enter into this market, which health insiders often refer to as "population health" or "care management." The population health market is large and growing, but crowded. To enter this space, a vendor like Verily would put forward a proposal to a payor — like the government, an employer or a private insurance company — detailing how it can bring down costs. If a company like Verily can deliver on that, the payor would share some portion of the amount saved. If costs don't come down, it might make no money from that contract. (This is a simplification, and the details vary by contract.) A classic intervention might involve analyzing health data to figure [...]

By |March 2nd, 2018|Blog, Consulting, doctor, doctor Credentialing, Healthcare Changes, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing, Verification|Comments Off on Google sister-company Verily is plotting a move into a fast-growing corner of the health insurance industry

Trump plan: Less health insurance for lower premiums

By RICARDO ALONSO-ZALDIVAR, ASSOCIATED PRESS WASHINGTON — Feb 20, 2018, 4:49 PM ET The Trump administration Tuesday spelled out a plan to lower the cost of health insurance: give consumers the option of buying less coverage in exchange for reduced premiums. The proposed regulations would expand an alternative to the comprehensive medical plans required under former President Barack Obama's health law. Individuals could buy so-called "short-term" policies for up to 12 months. But the coverage would omit key consumer protections and offer fewer benefits, making it unattractive for older people or those with health problems. The plans would come with a disclaimer that they don't meet the Affordable Care Act's safeguards, such as guaranteed coverage, ten broad classes of benefits, and limits on how much older adults have to pay. Insurers could also charge more if a consumer's medical history discloses health problems. Nonetheless, administration officials said they believe the short-term option will be welcomed by people who need an individual health insurance policy but don't qualify for the ACA's income-based subsidies. Those in this largely middle-class crowd make too much for subsidies and have absorbed years of price hikes. Some say they now face monthly, mortgage-size payments of well over $1,000 for health insurance. Then they usually have to pay a deductible of several thousand dollars. Research indicates the uninsured rate among these customers is growing. "If you are not subsidized, the options can be really unaffordable for folks," Health and Human Services Secretary Alex Azar told reporters. The administration estimates monthly premiums for a short-term plan could be about than one-third of what a comprehensive policy costs. Democrats swiftly branded it a return to "junk insurance," and the main insurance industry lobbying group [...]

California’s two health insurance regulators to investigate Aetna coverage decisions

LA TIMES - By BARBARA FEDER OSTROV- FEB 12, 2018 | 7:50 PM Both of California's health insurance regulators said they will investigate how Aetna Inc. makes coverage decisions, as the lawsuit of a California man who is suing the nation's third-largest insurer for improper denial of care heads for opening arguments Wednesday. The Department of Managed Health Care, which regulates the vast majority of health plans in California, said Monday it will investigate Aetna after CNN first reported Sunday that one of the Hartford, Conn., company's medical directors had testified in a deposition related to the lawsuit that he did not examine patients' records before deciding whether to deny or approve care. Rather, he relied on information provided by nurses who reviewed the records — and that was how he was trained by the company, he said. California Insurance Commissioner Dave Jones had already told CNN his office would investigate Aetna, which he reconfirmed in a statement Monday. "If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records, that is a significant concern and could be a violation of the law," Jones said. It isn't known how widespread the review of patient claims by non-physicians is in the industry. The California Department of Insurance, which Jones heads, regulates only a small fraction of the state's health plans, but they include several Aetna policies. He has previously criticized Aetna for "excessive" health insurance rate increases, although neither his agency nor the Managed Health Care Department has the power to stop the increases. Jones' investigation of Aetna will review denials of coverage or pre-authorizations during the tenure of the medical director who testified in the California lawsuit, Jay Ken Iinuma, who [...]

By |February 16th, 2018|Blog, Commercial Insurance, doctor, doctor Credentialing, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing, Staff Training|Comments Off on California’s two health insurance regulators to investigate Aetna coverage decisions

The Future of Healthcare Could Be a Privacy Nightmare

TONIC - Susan Rinkunas -Feb 8 2018, 10:54am The Amazon healthcare effort and CVS-Aetna merger raise lots of questions. Last Tuesday, Amazon, JP Morgan, and Berkshire Hathaway announced that they were coming together to do…something related to healthcare for their 1.2 million employees and could possibly expand to the public. We don’t know whether they’ll provide health insurance, offer health clinics at company buildings and/or Whole Foods stores, or just use their size to negotiate better prices with existing insurance companies. Despite the fact that we have next to zero information about what AmazonCare would actually be, the news still sent healthcare stocks falling and led to optimistic predictions and double-takes from doubters. And it has been freaking me out for the past week. Why? Millions of Americans are hooked on Amazon and its two-day shipping. We use it to order toiletries and home supplies, watch movies, and even get our groceries delivered. The site recommends products to you based on your order history. If the parent company is somehow involved in healthcare, it’s not that hard to imagine a world in which Amazon would use people’s health data to suggest products—or even actively try to stop people from buying “unhealthy” things.Is that imagined scenario something that could actually happen or more Black Mirror territory? I talked to a few privacy and health law experts about Amazon—as well as CVS, since CVS pharmacy and health insurer Aetna announced plans to merge in December. While that deal is still pending, it’s also a privacy minefield of healthcare-meets-retail. Initially, they made me freak out even more, but they also reminded me that there are still a lot of unknowns. I asked Frederik Zuiderveen Borgesius, a privacy researcher [...]

Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care

NY Times- By NICK WINGFIELD, KATIE THOMAS and REED ABELSON JAN. 30, 2018 SEATTLE — Three corporate behemoths — Amazon, Berkshire Hathaway and JPMorgan Chase — announced on Tuesday that they would form an independent health care company for their employees in the United States. The alliance was a sign of just how frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment. It also caused further turmoil in an industry reeling from attempts by new players to attack a notoriously inefficient, intractable web of doctors, hospitals, insurers and pharmaceutical companies. It was unclear how extensively the three partners would overhaul their employees’ existing health coverage — whether they would simply help workers find a local doctor, steer employees to online medical advice or use their muscle to negotiate lower prices for drugs and procedures. While the alliance will apply only to their employees, these corporations are so closely watched that whatever successes they have could become models for other businesses. Major employers, from Walmart to Caterpillar, have tried for years to tackle the high costs and complexity of health care, and have grown increasingly frustrated as Congress has deadlocked over the issue, leaving many of the thorniest issues to private industry. About 151 million Americans get their health insurance from an employer. But Tuesday’s announcement landed like a thunderclap — sending stocks for insurers and other major health companies tumbling. Shares of health care companies like UnitedHealth Group and Anthem plunged on Tuesday, dragging down the broader stock market. That weakness reflects the strength of the new entrants. The partnership brings together Amazon, the online retail giant known for disrupting major industries; Berkshire Hathaway, [...]

By |February 1st, 2018|amazon, Blog, Credentialing, doctor, doctor Credentialing, Health Insurance, Healthcare Professionals, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, medicare claims, Obamacare, Physician Credentialing|Comments Off on Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care

When your insurer denies a valid claim because of ‘lack of medical necessity’

Los Angeles Times- By DAVID LAZARUS -JAN 23, 2018 | 3:00 AM We learned last week that roughly 3.2 million more Americans were uninsured in 2017 — hard data attesting to how Republicans' cold-hearted obsession with overturning Obamacare is playing out in the real world. According to the Gallup-Sharecare Well-Being Index, the U.S. uninsured rate rose to 12.2% last year after plunging to a low of 10.9% by the end of 2016. Prior to Obamacare, the uninsured rate nationwide was as high as 18%. Yet the number of people covered is only half the healthcare story. The other is quality of coverage for those fortunate enough to have health insurance. Frequently, it can be a struggle for patients to receive coverage for legitimate claims. Denial letters from profit-minded insurers are an all-too-common aspect of our healthcare system, requiring patients and their families to jump through deliberately tedious bureaucratic hoops at a time when their attention is elsewhere. Count me among that number. I received a letter the other day from my employer's insurer, Blue Cross Blue Shield of Illinois, denying my claim for a new insulin pump. The reason: "Lack of medical necessity." This is intriguing on a number of levels: I have Type 1 diabetes, an incurable autoimmune disease requiring multiple daily insulin injections. It won’t just go away. I have used an insulin pump for the last nine years. I’ve never submitted a claim for a costly diabetes-related complication, such as neuropathy or retinopathy, so clearly I’m doing something right. If you’re an insurance company, you absolutely want to do whatever you can to save a buck by helping me manage this illness. I'm not sharing this out of self-interest. I fixed things prior [...]

By |January 25th, 2018|Blog, doctor, doctor Credentialing, Healthcare Professionals, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off on When your insurer denies a valid claim because of ‘lack of medical necessity’

This Company’s AI-Fueled Tech Is About to Bring Digital Health Care to Millions

FORTUNE- By SY MUKHERJEE 7:00 AM EST - JANUARY 17,2018 Digital health firm HealthTap and Bupa, a health care provider that offers both insurance and medical services to millions around the world, are teaming up in a massive strategic partnership that could make “digital end-to-end” medical services a widespread reality, HealthTap CEO Ron Gutman told Fortune in an early interview previewing the arrangement. Gutman describes it as the “biggest digital health deal” he knows of. That’s a bold claim; but the company’s new partnership with Bupa can’t be easily brushed off. Bupa does both the grunt work of medical care services (through hospitals and clinics) and the more heady business of insurance; it employs about 80,000 people around the world and has a far larger consumer base that stretches across the globe. By combining forces with Bupa, HealthTap’s artificial intelligence-powered services—which can allow patients to figure out whether they need to immediately go to a hospital if they’re feeling sick, access doctors through virtual visits, receive reminders about taking or refilling prescription medications, and generally keep one, unified record of their medical history—will be available to millions, according to the companies. Those are all goals (and technologies) that plenty of other digital health upstarts are seeking. So what makes HealthTap’s latest collaboration different? “Everything in one app,” says Gutman. He describes it as a true “end-to-end” digital service for medicine, where even the insurance part of the equation is taken care of within the app. “Over the past year we have worked together to implement a number of solutions for day-to-day customer needs, such as easily finding local doctors covered by Bupa insurance, scheduling physiotherapy, immunizations, and doctor visits with local clinics, and connecting residents in [...]

By |January 17th, 2018|Blog, doctor, doctor Credentialing, Healthcare Changes, Healthcare Professionals, ICD-10, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off on This Company’s AI-Fueled Tech Is About to Bring Digital Health Care to Millions

CVS-Aetna deserves chance to disrupt health-care system

THE HILL : BY DR. ROGER KLEIN, OPINION CONTRIBUTOR — 01/10/18 07:00 PM EST -THE VIEWS EXPRESSED BY CONTRIBUTORS ARE THEIR OWN AND NOT THE VIEW OF THE HILL On Dec. 3, drugstore chain CVS announced that it would purchase insurer Aetna for $69 billion, making this the largest health insurance merger in American history. The acquisition comes on the heels of a period of consolidation in the health-care industry that has been driven by rapidly increasing costs, declining reimbursement, technological change, increasing regulatory burdens and legislative changes, most prominently the Affordable Care Act. Its purpose is to allow these two entities to more effectively compete with other integrated providers like UnitedHealth Group, with its physician practices, surgery centers, urgent care clinics and pharmacy benefit manager, Kaiser Permanente, Geisinger Health System, more conventional providers like hospitals and physician groups and even disruptive retailers like Amazon. The CVS-Aetna merger is known as a “non-horizontal” merger. This means that the merging companies are neither actual nor potential competitors in the same markets. Instead, the CVS-Aetna combination brings together sellers whose relevant products are mostly complementary goods and services like prescription drugs, pharmacy benefit management, primary care and health insurance. The merger also has “vertical” elements. For example, health insurers are often purchasers of prescription drugs, pharmacy benefit management services, prescription drugs and other pharmacy products. Historically, federal enforcement activity has centered on “horizontal” mergers, that is, mergers of competitors. Typically, horizontal mergers present a greater risk of harming consumers than do non-horizontal mergers. However, the recent Justice Department lawsuit challenging AT&T’s $85 billion purchase of Time Warner and remarks Assistant Attorney General for the Antitrust Division Makan Delrahim made at an American Bar Association conference in November [...]