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Trump administration proposes new Medicare drug payment model to reduce costs

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Trump administration proposes new Medicare drug payment model to reduce costs

HEALTHCARE FINANCE- Susan Morse, Senior Editor October 25,2018 The International Pricing Index model would reset Medicare payments for physician-administered drugs. President Trump on Thursday proposed to reduce prescription drug costs in a move projected to save taxpayers and patients $17.2 billion over five years. America's Health Insurance Plans commends the proposed payment model, while the American Medical Association voiced more caution. Under the proposed International Pricing Index model, Medicare's payments for select physician-administered drugs would shift to a level more closely aligned with prices in other countries. The move from current payment levels to payment levels based on international prices would be phased in over a five-year period, would apply to 50 percent of the country, and would cover most drugs in Medicare Part B, which includes physician-administered medicines such as infusions, according to the Department of Health and Human Services. HHS said it is considering a randomized approach to determine which geographies in the country would participate. The Centers for Medicare and Medicaid Services is taking comments prior to issuing a proposed rule in the spring of 2019, with a potential start in spring 2020. WHY THIS MATTERS HHS contends the model would correct existing incentives to prescribe higher-priced drugs and, for the first time, address disparities in prices between the United States and other countries. Since patient cost sharing is calculated based on Medicare's payment amount, patients would see lower costs under the model, HHS said. TREND Physicians currently purchase the drugs they administer and receive payment from Medicare at an amount equal to the average sales price plus an add-on fee. The add-on is calculated as a percentage of the average sales price of the drug. This creates several problems, HHS said. First, [...]

By kristian|October 26th, 2018|Blog, Consulting, doctor, doctor Credentialing, Healthcare Changes, Healthcare Professionals, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off

CMS is allowing Medicare Advantage plans to cross negotiate Part B and D drug prices

Healthcare Finance - Susan Morse, Senior Editor - August 07, 2018 Starting in 2019, insurers may use step therapy to choose the least expensive drug first before moving on to another prescription. For the first time, Medicare Advantage plans that also offer a Part D benefit have the option of cross negotiating for Part B drugs to get the lowest price, the Centers for Medicare and Medicaid Services told MA organizations in a memo that went out today. Until now, Part B outpatient drugs and Medicare Part D drugs usually picked up at the pharmacy, have been kept separate. Part B drugs often have a competitor in Part D, but plans were not allowed to choose, according to CMS Administrator Seema Verma. Starting in 2019, MA plans that also offer a Part D benefit will be able to cross manage across B and D. In this way, competition is increased for the lower price, Verma said. It might help plans negotiate better discounts and direct patients to high value medications, she said. Part B drugs constitute around $12 billion per year in spending by plans. "As a result of the agency's action today, the Medicare Advantage plans that choose to offer this option will be able to have medicines in Part B compete on a level playing field with those in Part D," CMS said. The new guidance also allows plans to use step therapy, a practice banned in 2012. Step therapy gives the private sector MA plans the option of offering patients a preferred therapy first before moving on to another drug. It is a type of preauthorization for drugs that begins with the most preferred - which is often the least expensive therapy - [...]

By kristian|August 11th, 2018|Blog, Commercial Insurance, Consulting, Discount, doctor, doctor Credentialing, Health Insurance, Healthcare Changes, Healthcare Professionals, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off

CMS Plugs Changes to E/M Coding

by Shannon Firth, Washington Correspondent, MedPage Today- July 18, 2018 Agency argues that streamlined billing codes will reduce physician burden WASHINGTON -- Administration officials sought to explain the nuts and bolts of proposed changes to evaluation and management (E/M) codes during an online panel discussion on Wednesday. Last week, the Centers for Medicare and Medicaid Services (CMS) proposed several major changes to the Medicare physician fee schedule that the agency believes will greatly reduce some of the paperwork burden physicians face each day. By making documentation less onerous, CMS says it's giving physicians more time to focus on their patients and to improve their health outcomes. "If we're serious about improving the quality and access for patients we have to address the concerns of providers on the front lines," CMS Administrator Seema Verma said during Wednesday's webcast. Under the current system of E/M billing, providers must choose between category levels 1-5. Level 1 is reserved for non-physician services and level 5 is reserved for the most complex patients. "The differences between levels 2 to 5 are often really difficult to discern and time-consuming to document," said Kate Goodrich, MD, CMS's chief medical officer. Physicians are required to justify the level they choose by performing certain tasks, for example reviewing a certain number of organ systems during their physical exam, for level 3 and a different number for level 5, she explained. Also, under current E/M codes, each physician has to redocument a patient's past medical history, family history and social history even if the same histories were already taken and recorded by a previous provider, or during a previous visit. Under the new proposed rule, the agency "collapsed" the codes between 2 and 5, Goodrich said. [...]

By kristian|July 20th, 2018|Blog, Commercial Insurance, Consulting, Credentialing, doctor, doctor Credentialing, Health Insurance, Healthcare Changes, Healthcare Professionals, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Physician Credentialing|Comments Off

CMA News – Coding Corner : Modifier 59

California Medical Association News - Coding Corner: Modifier 59 -May 01, 2018 | Practice Management CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care. Modifier 59 Distinct procedural service is an “unbundling modifier.” When properly applied, it allows you to separately report—and to be reimbursed for—two or more procedures that normally would not be billed or paid independently during the same provider/patient encounter. For example, per CPT Assistant (Jan. 2018): Code 20680 [Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)] describes a unit of service that is typically reported only once, provided the original injury is located at only one anatomic site, regardless of the number of screws, plates, or rods inserted, or the number of incisions required for removal. The removal of a single implant system or construct, which may require multiple incisions (eg, intramedullary [IM] nail and several locking screws) is reported only once with code 20680. Reporting code 20680 more than once is appropriate only when the hardware removal is performed for another fracture(s) in a different anatomical site(s) unrelated to the first fracture (eg, ankle hardware and wrist hardware). In these circumstances, modifier 59, Distinct Procedural Service, would be appended to subsequent uses of the implant removal code. CPT® and CCI Conditions to Append Modifier 59 As outlined in the CPT® codebook, the general conditions under which you might append modifier 59 include situations where two or more CPT® codes, not normally reported together, are performed at a: Different session Different procedure or surgery [...]

By kristian|July 11th, 2018|Blog, Commercial Insurance, Consulting, Credentialing, doctor, doctor Credentialing, Healthcare Changes, Healthcare Professionals, ICD-10, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing, Staff Training|Comments Off

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Medicare Advantage Change Could Lead To Payments Opportunities

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Medicare Advantage Change Could Lead To Payments Opportunities

PYMNTS - June 7, 2018 One of the latest changes to federal rules regarding non-medical home care services could provide more business opportunity to firms that serve that market and handle such backend tasks as billing and payroll. In April, the U.S. Centers for Medicare and Medicaid Services (CMS) said that Medicare Advantage would, for the first time, cover those services, through which caregivers help senior citizens in their homes. The decision allows that care to be treated as a supplemental benefit under Medicare Advantage programs. “CMS is expanding the definition of ‘primarily health related’,” the federal agency said. “Under the new definition, the agency will allow supplemental benefits if they compensate for physical impairments, diminish the impact of injuries or health conditions and/or reduce avoidable emergency room utilization.” According to the CMS, 35 percent of Medicare beneficiaries take part in Medicare Advantage, with experts predicting significant increases in the years to come. “Insurers and payors have been positioning themselves to better align with post-acute care services for years. As the focus also shifts toward the high-cost, high-needs, dual-eligible patient populations of people who qualify for both Medicare and Medicaid, that has provided additional incentive to cover personal care services as well,” reported Home Health Care News. This is a significant deal for seniors, because they usually pay out of pocket for non-medical home care services, according to experts. And it could turn into a lucrative opportunity for companies active in this market, too. One such company, called Honor, partners with local home care agencies and other providers to manage such tasks as caregiver payroll, recruiting, scheduling, insurance and legal issues. In May, the company accounted a $50 million Series C funding round led by [...]

By kristian|June 7th, 2018|Blog, Consulting, Credentialing, doctor, doctor Credentialing, Healthcare Changes, Healthcare Professionals, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off

Trump’s new insurance rules are panned by nearly every healthcare group that submitted formal comments

Los Angeles Times - By NOAM N. LEVEY -MAY 30, 2018 | 3:00 AM | WASHINGTON More than 95% of healthcare groups that have commented on President Trump’s effort to weaken Obama-era health insurance rules criticized or outright opposed the proposals, according to a Times review of thousands of official comment letters filed with federal agencies. The extraordinary one-sided outpouring came from more than 300 patient and consumer advocates, physician and nurse organizations and trade groups representing hospitals, clinics and health insurers across the country, the review found. Kris Haltmeyer, vice president of health policy and analysis at the Blue Cross Blue Shield Assn., said he couldn’t recall a similar show of opposition in his more than 22 years at the trade group, which represents Blue Cross and Blue Shield health plans and is among the organizations that have expressed serious reservations about the administration’s proposed regulations. “This seems to be a pretty overwhelming statement of concern,” Haltmeyer said. State insurance regulators from both political parties have also warned that the administration’s proposals could destabilize insurance markets, raise premiums for sick Americans and open the door to insurance fraud. And dozens of industry leaders and other experts have called on the administration to rethink moves to scale back consumer protections enacted through the Affordable Care Act, often called Obamacare. “Basically anybody who knows anything about healthcare is opposed to these proposals,” said Sandy Praeger, a former Republican state insurance regulator in Kansas and onetime president of the National Assn. of Insurance Commissioners. “It’s amazing.” Obamacare 101: A primer on key issues in the debate over repealing and replacing the Affordable Care Act. » After the failure to repeal the healthcare law last year, the Trump administration is [...]

By kristian|May 30th, 2018|Blog, Commercial Insurance, Consulting, Credentialing, doctor, doctor Credentialing, Health Insurance, Healthcare Changes, Healthcare Professionals, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing, Staff Training|Comments Off

Trump Promises Lower Drug Prices, but Drops Populist Solutions

NY Times- By Robert Pear May 11, 2018 WASHINGTON — President Trump vowed on Friday to “bring soaring drug prices back down to earth” by promoting competition among pharmaceutical companies, and he suggested that the government could require drugmakers to disclose prices in their ubiquitous television advertising. But he dropped the popular and populist proposals of his presidential campaign, opting not to have the federal government directly negotiate lower drug prices for Medicare. And he chose not to allow American consumers to import low-cost medicines from abroad. He would instead give private entities more tools to negotiate better deals on behalf of consumers, insurers and employers. Speaking in the sun-splashed Rose Garden of the White House, Mr. Trump said that a “tangled web of special interests” had conspired to keep drug prices high at the expense of American consumers. “Everyone involved in the broken system — the drugmakers, insurance companies, distributors, pharmacy benefit managers and many others — contribute to the problem,” Mr. Trump said. “Government has also been part of the problem because previous leaders turned a blind eye to this incredible abuse. But under this administration we are putting American patients first.” His proposals hardly put a scare into the system he criticized. Ronny Gal, a securities analyst at Sanford C. Bernstein & Company, said the president’s speech was “very, very positive to pharma,” and he added, “We have not seen anything about that speech which should concern investors” in the pharmaceutical industry. Shares of several major drug and biotech companies rose immediately after the speech, as did the stocks of pharmacy benefit managers, the “middlemen” who Mr. Trump said had gotten “very, very rich.” The Nasdaq Biotechnology Index rose 2.7 percent on Friday. [...]

By kristian|May 13th, 2018|Blog, Commercial Insurance, Consulting, doctor, doctor Credentialing, Health Insurance, Healthcare Changes, ICD-10, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off

Medicare Advantage Plans Can Pay for Many LTC Services in 2019: Feds

Plans could cover adult day care, respite care and in-home support services. By Allison Bell | May 02, 2018 at 10:27 AM The Centers for Medicare and Medicaid Services is getting ready to let Medicare Advantage plan issuers add major new long-term care benefits to their supplemental benefits menus. The Better Medicare Alliance, a Washington-based coalition for companies and groups with an interest in the Medicare Advantage has posted a copy of a memo that shows CMS is reinterpreting the phrase “primarily health related” when deciding whether a Medicare Advantage plan can cover a specific benefit. Kathryn Coleman, director of the CMS Medicare Drug & Health Plan Contract Administration Group, writes in the memo, which was sent to Medicare Advantage organizations April 27, that CMS will let a plan cover adult day care services for adults who need help with either the basic “activities of daily living,” such as walking or going to the bathroom, or with “instrumental activities of daily living,” such as the ability to cook, clean or shop. A Medicare Advantage plan could not, apparently, cover skilled nursing home care, or assisted living facility fees. But, in addition to adult day care, a Medicare Advantage plan could pay for: In-home support services to help people with disabilities or medical conditions perform activities of daily living and instrumental activities of daily living within the home, “to compensate for physical impairments, ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and health care utilization.” Short-term “respite care” or other support services for family caregivers. Making non-Medicare-covered safety changes, such as installing grab bars, that might help people stay in their homes. Non-emergency transportation to health care services. (Plans can already [...]

By kristian|May 3rd, 2018|Blog, Commercial Insurance, Consulting, Credentialing, Discount, doctor, doctor Credentialing, Health Insurance, Healthcare Professionals, ICD-10, ICD-10, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off

Medicare Advantage Plans Cleared To Go Beyond Medical Coverage — Even Groceries

Kaiser Health News- By Susan Jaffe - APRIL 3, 2018 Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits added to Medicare Advantage coverage when new federal rules take effect next year. On Monday, the Centers for Medicare & Medicaid Services (CMS) expanded how it defines the “primarily health-related” benefits that insurers are allowed to include in their Medicare Advantage policies. And insurers would include these extras on top of providing the benefits traditional Medicare offers. “Medicare Advantage beneficiaries will have more supplemental benefits making it easier for them to lead healthier, more independent lives,” said CMS Administrator Seema Verma. Of the 61 million people enrolled in Medicare last year, 20 million have opted for Medicare Advantage, a privately run alternative to the traditional government program. Advantage plans limit members to a network of providers. Similar restrictions may apply to the new benefits. Many Medicare Advantage plans already offer some health benefits not covered by traditional Medicare, such as eyeglasses, hearing aids, dental care and gym memberships. But the new rules, which the industry sought, will expand that significantly to items and services that may not be directly considered medical treatment. CMS said the insurers will be permitted to provide care and devices that prevent or treat illness or injuries, compensate for physical impairments, address the psychological effects of illness or injuries, or reduce emergency medical care. Although insurers are still in the early stages of designing their 2019 policies, some companies have ideas about what they might include. In addition to transportation to doctors’ offices or better food options, some health insurance experts said additional benefits could include simple modifications in beneficiaries’ homes, such [...]

By kristian|April 6th, 2018|Blog, Commercial Insurance, Consulting, Credentialing, doctor, doctor Credentialing, Health Insurance, Healthcare Professionals, ICD-10, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off

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

Blog, Consulting, doctor, doctor Credentialing, Healthcare Changes, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Obamacare, Physician Credentialing, Verification

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 kristian|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

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