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The FIRM provides professional claims billing services for individual providers, clinics and facilities. We service all disciplines of practice, i.e., medical, dental, diagnostic testing, chiropractic, physical therapy, optometry/ophthalmology, mental health, chemical dependency, and durable medical equipment.

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On children’s health coverage, congressional inaction has brought us to the ‘nightmare scenario’

LA TIMES - Micahel Hiltzik- November 27, 2017 Child healthcare advocates have been warning, and warning, and warning that Congress’ delay on reauthorizing funds for the Children’s Health Insurance Program places health coverage for as many as 9 million children and pregnant women at risk. But since the funding expired Sept. 30, there has been no action by Congress. Now, advocates say, “the nightmare scenario is close” for states across the country, to quote former Medicare and Medicaid chief Andrew Slavitt, as the state-federal program runs out of federal money. State officials in Colorado started sending letters to families on CHIP as early as Monday, warning them that their kids’ health insurance could run out Jan. 30 and they should “start researching private health insurance options.” If Congress doesn’t vote within two weeks to resume the program’s $15 billion in annual funding, the state officials said, they would send out official notification of the program’s cancellation. A similar high-wire act is playing out in at least 11 states whose CHIP coffers will be exhausted by the end of December, according to the Kaiser Family Foundation; that roster includes California. In Colorado and 20 others, there’s just enough money left from earlier appropriations to last into the first month or so of 2018. We’ve sounded the alarm about the expiration of CHIP in four columns since May, when congressional dysfunction built to the point that a reauthorization of CHIP by Sept. 30 began to look doubtful. The fears of children’s advocates proved true when the deadline passed without a vote; but even then most assumed that the delay would be brief, and the issue would be resolved before too many states had to take stringent measures. [...]

By |December 1st, 2017|Blog, Commercial Insurance, Credentialing, doctor, doctor Credentialing, Healthcare Changes, Healthcare Professionals, Medicaid, Medical Billing, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, medicare claims, Obamacare, Physician Credentialing|Comments Off on On children’s health coverage, congressional inaction has brought us to the ‘nightmare scenario’

I.R.S. Starts to Enforce Health Law’s Rule That Employers Offer Insurance

NY TIMES- By STACY COWLEY NOV. 16, 2017 As Republicans and the Trump administration continue trying to chip away at the Affordable Care Act, the Internal Revenue Service has begun, for the first time, to enforce one of the law’s most polarizing provisions: the employer mandate. Thousands of businesses — many of them small or midsize — will soon receive a letter saying that they owe the government money because they failed to offer their workers qualifying health insurance. The first round of notices, which the I.R.S. began sending late last month, are being mailed to companies that have at least 100 full-time employees and ran afoul of the law in 2015, the year that the mandate took effect. Large companies, defined in the law as those with 50 or more workers, are required to offer their employees affordable insurance or pay stiff tax penalties. The I.R.S. held off for years on assessing those fines, saying that it needed more time, and money, to build its compliance systems. Now, the agency says it is finally ready to go after scofflaws. “As the I.R.S. has publicly stated, the agency is obligated to enforce the Affordable Care Act’s employer shared responsibility provision,” said Bruce Friedland, an agency spokesman. Ten months ago, in his first executive order, President Trump directed government agencies to waive, defer or delay carrying out as much of the law as possible. This week, the Treasury Department said that it objected to the employer mandate but was legally compelled to enforce it. “Treasury lawyers see no ground for the secretary to direct the I.R.S. to not collect the tax,” the agency said in a written statement. “The A.C.A.’s employer mandate unfortunately remains the law of [...]

By |November 16th, 2017|Blog, Credentialing, doctor, doctor Credentialing, Healthcare Changes, Healthcare Professionals, ICD-10, Medical Billing, Medical Coding, Medical Credentialing, Medical Insurance, Medicare, medicare claims, Physician Credentialing|Comments Off on I.R.S. Starts to Enforce Health Law’s Rule That Employers Offer Insurance

Insurers make billions off Medicaid in California during Obamacare expansion

Los Angeles Times - Chad Terhune and Anna Gorman- NOVEMBER 6, 2017 Medicaid is rarely associated with getting rich. The patients are poor, the budgets tight and payments to doctors often paltry. But some insurance companies are reaping spectacular profits off the taxpayer-funded program in California, even when the state finds that patient care is subpar. Health Net, a unit of Centene Corp., the largest Medicaid insurer nationwide, raked in $1.1 billion in profit from 2014 to 2016, according to state data obtained by Kaiser Health News. Anthem, another industry giant, turned a profit of $549 million from California’s Medicaid program in the same period. Overall, Medicaid insurers in the Golden State made $5.4 billion in profits from 2014 to 2016, in part because the state paid higher rates during the inaugural years of the nation’s Medicaid expansion under the Affordable Care Act, or Obamacare. Last year, they made more money than all Medicaid insurers combined in 34 other states with managed care plans. “Those profits are gigantic — wow,” said Glenn Melnick, a health economist and professor at USC. Alan Sager, a health-policy professor at Boston University, was surprised — and dismayed. “California is being wildly open handed and excessively generous with insurers,” he said. Jennifer Kent, California’s Medicaid director, said that health plan profits were higher than anticipated during the ACA expansion. But she said the state expects to recoup a significant amount of money within the next year once audits are complete and other retroactive rate adjustments are made. “We’re going to be taking a lot of money back. We’re talking billions of dollars,” Kent said in an interview Friday. No one should think “these plans just made off like bandits and [...]

By |November 9th, 2017|Blog, Commercial Insurance, Credentialing, doctor, doctor Credentialing, Healthcare Professionals, Medicaid, Medical Coding, Medical Compliance, Medical Credentialing, Medical Insurance, Medicare, Medicare, medicare claims, Obamacare, Physician Credentialing|Comments Off on Insurers make billions off Medicaid in California during Obamacare expansion

Wall Street Sees a CVS, Aetna Deal as a Revolutionary Defense

Bloomberg - By Cristin Flanagan October 27, 2017, 7:56 AM PDT Speculation that CVS Health Corp may be making a play to buy Aetna Inc yesterday followed hot on the heels of report that Amazon Inc. had received pharmacy-wholesaler licenses in a dozen states. While a pharmacy acquiring a health insurer may be an unusual step, analysts see it as potentially bold move to fend of the looming Amazon threat and enter an “evolutionary and revolutionary” new world in health care. Others, however, saw an expensive deal and question whether Aetna would be a willing seller. CVS and Aetna shares both fell on Friday morning, down as much as 4.7 percent and 2.9 percent respectively. “We see this potential deal as both evolutionary and revolutionary given the dynamic healthcare environment and push toward consumerism coupled with a challenged retail backdrop and the need to combat a looming Amazon threat. In our opinion, the merits of the deal and potential new model is conceptually compelling, with the biggest questions admittedly, execution, integration, and the structure of the deal. Based on our analysis, we estimate the deal could be 24 cents per share, or 3.7 percent accretive to CVS in year one with greater upside over time if the combined entity successfully manages down healthcare cost. “Could they even do the deal? It’s possible. The reported deal could imply a takeout value of 12.4x trailing 12 months (TTM) Ebitda by our estimate. Based on CVS’ acquisitions of Caremark (in 2006 for 11.8x TTM Ebitda), and Omnicare (in 2015 for 22.0x TTM Ebitda), this deal could be in bounds.” “We think a CVS / AET combination makes a lot of sense. We would imagine a scenario that CVS expands its [...]

Did Medicaid Expansion Cause The Opioid Epidemic? There’s Little Evidence That It Did.

Health Affairs Blog- Andrew Goodman-Bacon and Emma Sandoe -August 23, 2017 Recent health reform debates have generated a new theory that claims that the Affordable Care Act’s (ACA) Medicaid expansion has either caused or exacerbated the opioid epidemic. The logic on its face seems clear: legal prescriptions fuel the opioid epidemic, Medicaid increases access to prescription opioids, hence the Medicaid expansion contributes to, or has even caused the epidemic. Proponents of this view point to a rise in opioid-related deaths in ACA Medicaid expansion states relative to non-expansion states. Political commentators, including some politicians, use this claim to justify their support for federal Medicaid cuts, despite the fact that Medicaid finances a significant amount of treatment for opioid use disorder. In this post, we argue that evidence for the claim that the ACA’s Medicaid expansion caused or exacerbated the opioid epidemic is not credible. First, trends in opioid deaths nationally and by Medicaid expansion status predate the ACA. Second, counties with the largest coverage gains actually experienced smaller increases in drug-related mortality than counties with smaller coverage gains. Third, the fact that Medicaid recipients fill more opioid prescriptions than non-recipients largely reflects greater levels of disability and chronic illness in the populations that Medicaid serves. While we do not reject the possibility that public policy has played a role in our current prescription abuse crisis, on balance we find little evidence to support the idea that Medicaid caused or worsened the epidemic. Existing Evidence On Medicaid And Opioids Comparing Medicaid Recipients To Non-Recipients Proponents of the view that Medicaid exacerbates drug abuse often cite the fact that Medicaid recipients are prescribed more opioids than non-recipients. In the early 2000s, for example, Medicaid enrollees in New York [...]

Soaring Health Insurance Profits Add Intrigue To Obamacare Debate

Hartford Courant - Dan Haar- August 10,2017 It was a tense winter for Aetna, Cigna and the other giant national managed health care companies. Their mega-mergers collapsed in lawsuits by the Obama administration’s Department of Justice. The Trump administration’s promise to undo Obamacare injected uncertainty into the market. Profits at the end of 2016 were less than stellar except at UnitedHealth Group, the biggest of the five. A slowdown or even the end of a yearslong run-up in share prices that had seen the insurers far outpace the markets seemed possible. Months later, the party hasn’t slowed, it’s picked up even more energy. The companies — Aetna, Cigna, UnitedHealth, Humana and Anthem — have earned record or near-record profits in 2017 and their stock values continue to soar. Aetna and Cigna are each up five-fold from March 2010, the month the Affordable Care Act took effect. UnitedHealth is up more than six-fold. In the spring quarter, Aetna earned $1.2 billion in operating profit after taxes, more than double its quarterly average since Obamacare started. Cigna shares are up 31 percent in 2017. Could all this success bring a cost as the nation endures rising prices and political gridlock over reform? For the Big Five, it’s a sweet-spot built on a solid foundation: commercial health plans enjoying flat use of medical services by middle-class customers who now must pay thousands of dollars out of their own pockets; cost-cutting by the companies; growing Medicare and Medicaid management business; and broad exits from the perilous Obamacare exchanges. The profits and the market gains are drawing attention, not all of it welcome. Consumers don’t like paying rising premiums and big bucks for medical services that were once fully covered [...]

Covered California premiums will rise 12.5%, and Anthem Blue Cross cuts coverage

Los Angeles Times- Soumya Karlamangla Contact Reporter -August 1, 2017 @ 4:15pm Amid uncertainty over the future of the Affordable Care Act, California officials announced Tuesday that monthly premiums for health plans sold on the state’s Obamacare exchange will rise by an average of 12.5% next year. Covered California, the state insurance marketplace, provides coverage to about 1.5 million people, the majority of whom receive subsidies that lower their premiums under the Affordable Care Act. Insurance plans for next year will be available for purchase in California from Nov. 1 to Jan 31. Next year, about 10% of people enrolled through the exchange will have to look for a new plan because Anthem Blue Cross will end its coverage in most of the state. State officials said Tuesday that Anthem will continue providing coverage only in Santa Clara County and parts of Northern California and the Central Valley. The announcement comes a week after a Republican plan to unwind key pieces of the Affordable Care Act — also known as Obamacare — failed in the U.S. Senate. President Trump has repeatedly urged lawmakers to keep working on a bill. Those repeal efforts, and Trump’s suggestions that he will not enforce the mandate that requires all Americans to have insurance, could lower enrollment this year, experts say. Next year’s premium estimates probably reflect insurers’ fears that not enough people will sign up for insurance, or that only sick people will enroll and their costs will be too high, experts say. “It’s not like we have a steady market. In fact, we have a market that’s in turmoil because of politics,” said Gerald Kominski, director of the UCLA Center for Health Policy Research. Sabrina Corlette, a research professor [...]

By |August 3rd, 2017|Blog, Commercial Insurance, Credentialing, doctor Credentialing, Healthcare Changes, Medical Insurance, Obamacare, Physician Credentialing|Comments Off on Covered California premiums will rise 12.5%, and Anthem Blue Cross cuts coverage

Why Obamacare Is Still in Peril

NY Times - By THE EDITORIAL BOARD JULY 28, 2017 In a dramatic last-minute spectacle, the latest Republican plan to destroy the Affordable Care Act was defeated early Friday because of the courageous votes of three senators: Susan Collins, John McCain and Lisa Murkowski. This will come as an immense relief to millions of Americans who stood to lose their health insurance, but it would be naïve to think that this is the end of the road for the repeal-Obamacare movement. For the last seven years, Republican leaders have engaged in a fraudulent campaign against the A.C.A. based on the lie that the law is either unworkable or collapsing. The law, which is based on conservative market-based ideas, is certainly flawed and could be improved, but it has helped 20 million people gain insurance and, as a result, provided needed medical care to the poor and the sick. Not only was the Republican diagnosis wrong, but also leaders like the House speaker, Paul Ryan, and the Senate majority leader, Mitch McConnell, tried to push through legislation that was devoid of any ideas and would have weakened the health care system and left millions unable to afford health care. One telling sign: Insurance companies, hospitals, doctors and public interest groups like AARP opposed pretty much every proposal the Republicans put out over the last seven months. Ultimately, this deceitful campaign ran aground by the narrowest of margins in the Senate thanks to the three Republicans and all 48 Democrats and independents. Much attention has rightly focused on Mr. McCain. Returning to the Senate after surgery and a brain cancer diagnosis, he delivered a stirring speech on Tuesday calling on lawmakers from both parties to reach “agreements made [...]

Even Talking About Weakening Obamacare Provisions Weakens The Exchanges

NPR- July 21, 201710:56 AM ET DANIELLE KURTZLEBEN The Affordable Care Act is not "exploding" or "imploding," as President Trump likes to claim. But Trump does hold several keys to sabotaging the insurance marketplaces, should he so choose — one of which his administration is reportedly weighing using. Every month, the Trump administration faces a deadline to pay what are called "cost-sharing reduction" (or CSR) subsidies to insurers. Those are subsidies that reimburse insurers to help low-income marketplace customers afford health care, on top of the tax credits that help those people pay their premiums. A lawsuit filed by House Republicans during the Obama era has left the fate of those payments uncertain. Trump reportedly wants to end the payments, as Politico reported, but the White House chose this week to continue the payments once again. Still, the ongoing ambiguity about the future of the payments is apparently causing premiums to rise and insurers to pull out of markets. Obamacare isn't "imploding," but insurers are shaken Recent analyses from multiple organizations (including the Department of Health and Human Services itself) show that the exchanges aren't imploding; in fact, they're relatively stable. But the Affordable Care Act, also known as Obamacare, does have its problems: Premiums continue to increase, as they did throughout Obama's presidency (though subsidies have shielded a majority of people on the exchanges from those increases), and insurers have backed out of exchanges. Ending the CSR payments could be catastrophic for the exchanges. It could cause premiums to rise by 19 percent or even more, as the Kaiser Family Foundation found in a recent analysis — and that assumes that insurers even stay in the exchanges, Kaiser added. Uncertainty Over Obamacare Leaves Next Year's Rates [...]

Major insurance groups call part of health bill ‘unworkable’

By ALAN FRAM, ASSOCIATED PRESS WASHINGTON — Jul 15, 2017, 11:21 AM ET Two of the insurance industry's most powerful organizations say a crucial provision in the Senate Republican health care bill allowing the sale of bare-bones policies is "unworkable in any form," delivering a blow to party leaders' efforts to win support for their legislation. The language was crafted by conservative Sen. Ted Cruz, R-Texas, and leaders have included it in the overall bill in hopes of winning votes from other congressional conservatives. But moderates have worried it will cause people with serious illnesses to lose coverage, and some conservatives say it doesn't go far enough. Two of the 52 GOP senators have already said they will oppose the legislation. Senate Majority Leader Mitch McConnell cannot lose any others for the legislation to survive a showdown vote expected next week. The overall measure represents the Senate GOP's attempt to deliver on the party's promise to repeal President Barack Obama's health care law, which they've been pledging to do since its 2010 enactment. The criticism of Cruz's provision was lodged in a rare joint statement by America's Health Care Plans and the BlueCross BlueShield Association. The two groups released it late Friday in the form of a letter to McConnell, R-Ky. "It is simply unworkable in any form," the letter said. They said it would "undermine protections for those with pre-existing medical conditions," increase premiums and lead many to lose coverage. The provision would let insurers sell low-cost policies with skimpy coverage, as long as they also sell policies that meet a stringent list of services they're required to provide under Obama's law, like mental health counseling and prescription drugs. Cruz says the proposal would [...]