From Medicare Advantage News - Medicare-Medicaid dual eligibles have worse outcomes than non-duals on many CMS star-rating measures not because of the plan’s quality of service but instead because of characteristics of the duals themselves, according to the final report of a large-scale, multivariate study by Inovalon, Inc. The conclusions in the report issued March 31 build on those in preliminary findings released last October by Inovalon (MAN 11/6/14, p. 1) — but apparently did not influence CMS’s decisions in the final 2016 Medicare Advantage pay notice sent out April 6 (see story, p. 1). Read more
From Health Plan Week - Moves by PBMs, in collaboration with health plans, to stomp out what are considered by payers to be overpriced, unnecessary and borderline or actually fraudulent costs tied to compounded drugs has started to dramatically cut accepted claims for pain management, hormone replacement and other uses of these mostly topical creams formulated in special compounding pharmacies. Read more
From Inside Health Insurance Exchanges - At least two private exchange vendors say they have a workaround for federally facilitated exchange (FFE) states if the Supreme Court determines federal subsidies can be distributed only through state-based exchanges (SBEs). Private exchanges could be very helpful to states in providing the “back office” infrastructure and the IT platform needed to operate their own ACA exchanges, says Mark Hall, a professor of law and public health at Wake Forest University. Read more
From Medicare Advantage News - Providence Health Plan, which has a five-star Medicare Advantage plan with a long track record of success in its care management programs, will start in July an in-home multidisciplinary care program of both scheduled and unscheduled provider visits for frail and vulnerable members. The program will target about 2,200 of the MA plan’s approximately 46,000 members, selecting them based on algorithms that screen for such variables as multiple chronic conditions,… Read more
From Drug Benefit News - In a move that surprised many industry analysts, UnitedHealth Group on March 30 unveiled plans to acquire stand-alone PBM Catamaran Corp. and merge it with the health plan operator’s PBM unit, OptumRx. The combined firm will process approximately 1 billion prescriptions per year, securing OptumRx’s spot as the third-largest PBM. Under the agreement, UnitedHealth Group will acquire Catamaran’s outstanding common stock for $61.50 per share in cash. Read more
From Report on Medicare Compliance - For the second time in six months, a hospital has settled a case over alleged violations of CMS provider-based regulations. Hospitals are vulnerable in this area because of the many technical requirements for provider-based status, and CMS in particular is cracking down on shared-space arrangements, lawyers say. W.A. Foote Memorial Hospital, doing business as Allegiance Health in Michigan, agreed to pay $2.635 million in a civil monetary penalty settlement with the… Read more
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