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From Report on Medicare Compliance - CMS has instructed Medicare administrative contractors (MACs) to get off the sidelines and defend claim denials that are appealed to administrative law judges. In Medicare Transmittal 543, which takes effect Oct. 27, CMS says MAC physicians should make a case for some MAC medical review decisions that resulted in claim denials, were appealed by providers up the chain and are now scheduled for ALJ hearings. Not all ALJ hearings require their presence, but MAC physicians (e.g., contractor medical directors, employed physicians) should attend when certain planets align, CMS said. Read more

From Health Plan Week - Globetrotting Americans may be falling through the cracks of the Affordable Care Act, says GeoBlue, which on Sept. 30 hit the market with its new Xplorer Select plan that allows U.S. expatriates and mobile world travelers living stateside in stretches to buy coverage that fulfills the ACA’s individual mandate requirements. This new product is an example of how health plans are seeking fatter margin businesses by serving Americans living overseas… Read more

From ACO Business News - It’s not easy to earn shared savings in either of Medicare’s accountable care organization programs: Only about one-quarter of Medicare Shared Savings Program (MSSP) ACOs will get a payout, along with half the Pioneers, financial and quality results released last month by CMS indicate. The results were positive for CMS, which was able to tout that 11 Pioneers and 53 MSSP providers had saved CMS $372 million while improving quality (see… Read more

From Medicare Advantage News - It was largely more of the same in the new National Committee for Quality Assurance (NCQA) rankings of Medicare Advantage plans. Kaiser Permanente plans occupied the first three places, as they did a year ago (MAN 10/10/13, p. 3). And not a single PPO made it into the top 23 in the rankings, which were released last month and again were prepared in partnership with Consumer Reports magazine. But while… Read more

From Drug Benefit News - CVS Health’s CVS/caremark PBM unit will pay the U.S. $6 million to settle allegations that it knowingly failed to reimburse Medicaid for prescription drug costs that were the responsibility of private health plans administered by the PBM, the U.S. Department of Justice said on Sept. 26. The settlement comes as a result of a whistleblower lawsuit filed by former Caremark employee Donald Well. Read more

From Report on Medicare Compliance - Providers who fail meaningful-use audits apparently will face a second audit in addition to having their entire incentive payment recouped for the audit period. They have just one shot at reversing adverse audit findings through the informal appeal process established by CMS under the Medicare-Medicaid electronic health record (EHR) incentive payment program. But there may be more wiggle room in practice than on paper, possibly to keep providers from losing… Read more

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