AIS Blogs | AIS Health

2014 Is Turning Into a Lab Experiment for Health Plans

By Patrick Connole - May 7, 2013 - Comments

Health insurers, like all stakeholders, have no idea what the advent of public health insurance exchanges next year will look like. Will these new marketplaces even get off the ground in time for open enrollment this fall? Will there be a flood or a trickle of new lives for insurers to cover in the exchanges? How will state-run exchanges differ from federally facilitated or state partnership marketplaces? Increasingly, the talk in the industry is that 2014 will be a year of trial and error for... Read more

Is There a Link Between Soaring Costs and Poor Management in the ER?

By Rick Biehl - April 17, 2013 - Comments

On several recent occasions, I’ve witnessed first-hand the operation of hospital emergency rooms, as a patient and while accompanying family members. Two things stand out about these three separate experiences: (1) how hard-working and fantastic all of the individuals were who treated us; and (2) how ridiculously poorly managed all of the ERs were. Most recently, my daughter received 30 minutes of superb medical care by a wonderful team of doctors, nurses and technicians. Read more

‘A Foot in Each Canoe’

By Jill Brown - April 15, 2013 - Comments

Cambridge, Mass.-based Mount Auburn Hospital may be moving downriver toward full global risk, with more than 150 physician employees, a 513-physician-member independent practice association (IPA), one-third of hospital revenue from risk payers and bragging rights as the first hospital to enter into Blue Cross Blue Shield of Massachusetts’ Alternative Quality Contract, a modified global payment model. Read more

Going ‘Off-Cycle’ Extends Coverage, Making Some Unhappy

By Patrick Connole - April 9, 2013 - Comments

Health plans are trying to figure out a number of strategies ahead of major changes to the marketplace next year, from how and where to participate in state-based health insurance exchanges to how to treat existing customers in small-group plans who may want to extend their current coverage deep into 2014. Industry watchers say extending coverage for small-group plans into 2014 by resetting the clock on a plan’s cycle to an off-cycle setting in order to avoid the effects of the health reform... Read more

For ACOs, Telemonitoring Extends Scarce Resources

By Jill Brown - March 22, 2013 - Comments

To Doreen Salek, a director at Geisinger Health Plan, the math is pretty simple. Hire 3,000 registered nurses — if you can find them — to staff a full RN case management model for a large accountable care organization (ACO). Read more

Opinions Vary on How Health Plans Handle Government Payments

By Patrick Connole - February 25, 2013 - Comments

Most financial analysts greeted the news from CMS on Feb. 15 about proposed lower-than-expected Medicare payment rates with some form of surprise and dread. Medicare Advantage (MA) plans will be hit especially hard if the agency comes back with a final version of its rate structure for 2014 that looks like the draft. The question isn’t how bad will it be. Everyone knows that now. And even if the rates are tweaked a bit, MA plans will have to consider a number of options, including dropping out... Read more

Posting of Proposed Premiums May Push Competition

By Steve Davis - May 17, 2013 - Comments

If Oregon’s recent decision to publish proposed rates is any indication, public insurance exchanges could force health plan operators to be more competitive — or at least spend more time cross-checking their math. Proposed prices for Bronze-level individual coverage ranged from $169 to $422, prompting at least one carrier to seek permission to go back to the drawing board. Read more

Are the Wheels Falling Off the Federal Exchange Bus?

By Steve Davis - April 23, 2013 - Comments

Over the past month, HHS pushed some insurance exchange elements to the back burner — or off the stove completely — until 2015. Given tight deadlines to start up exchanges and the federal data hub, it’s not surprising that HHS is focusing on just that — and delaying some nonessential elements. But what else might be delayed? And will exchanges, navigators, in-person assisters and the data hub all be ready to enroll the previously uninsured on Oct. Read more

More States Balk at Enforcing Affordable Care Act’s Market Reforms Next Year: PART II

By Neal Learner - April 22, 2013 - Comments

Some states have told CMS they lack legal authority, or are otherwise unwilling, to enforce the Affordable Care Act’s market-reform provisions that kick in next year. AIS’s Health Reform Week (HRW) discussed the situation with Katie Keith, J.D., assistant research professor at the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms. She is co-author of a Commonwealth Fund report that found few states so far have enacted new legislation to oversee the ACA’s market... Read more

More States Balk at Enforcing Affordable Care Act’s Market Reforms Next Year

By Neal Learner - April 5, 2013 - Comments

An increasing number of states are telling CMS that they lack legal authority, or are otherwise unwilling, to enforce the Affordable Care Act’s (ACA) market-reform provisions that kick in next year. As of April 5, six states had balked at the insurance oversight duties, up from four states at the beginning of last month. Read more

Carriers Must Reach ‘Nomophobiacs’ on Their Terms

By Steve Davis - March 27, 2013 - Comments

This month, I traveled to The World Congress Summit on Consumer Engagement Through Health Plan Innovation outside of Orlando, Fla. In one of the more thought-provoking sessions, Bill Lan, who heads industry and insurance at Google, Inc., warned insurers that they will be left in the dust if they don’t develop a digital presence that lets consumers connect through a variety of formats. He noted that purchases of mobile devices have surpassed desktops, and having a website isn’t enough. Read more

Insurers Should Take Proactive Steps to Explain Expected Premium Hikes, Consultant Advises

By Neal Learner - March 22, 2013 - Comments

Insurance premiums are widely expected to jump next year as the new underwriting restrictions of the Affordable Care Act (ACA) take effect. Indeed, The Wall Street Journal (WSJ) on March 22 reported that UnitedHealth Group Inc. recently indicated premiums for some consumers buying individual plans could go up as much as 116% and small-business rates as much as 50%. Read more

CMS Fine-tunes MA Plan Audit Methodology — and Is Transparent About It

By James Gutman - May 10, 2013 - Comments

CMS seems to be taking its own advice when it comes to continuous quality improvement — at least in the program audits of Medicare Advantage plans. As outlined by agency speakers at the CMS MA and Part D spring conference May 6, there has been an overhaul of the methodology used in the audits starting this year in order to put the emphasis on finding the most serious problems and dealing with them severely. Read more

How to Weaken a Good CMS MA/Part D Conference

By James Gutman - May 6, 2013 - Comments

There probably was no good way for CMS to deal with its annual spring Medicare Advantage and Part D conference in light of sequestration-related budget cuts and furloughs. What has been in previous years an in-person (as well as webcast) conference with no registration fee could not be cost-justified now, so the only alternatives were to not hold the conference at all or to make it webcast only. Read more

Meet the New Bogeyman for MA: Sequestration

By James Gutman - April 26, 2013 - Comments

So you thought that the Medicare Advantage industry might have a little time to catch a breather since the final 2014 payment rates released April 1 were improved substantially from the preliminary ones unveiled Feb. 15? Think again. Read more

Is This the Fox and Hen Jointly Guarding the Henhouse?

By James Gutman - April 11, 2013 - Comments

Many large for-profit Medicare Advantage insurers are working more closely with providers than ever before, but perhaps only Universal American Corp. has taken the concept of a partnership this far. The MA sponsor is working with providers — especially long-term care facility operators — to start MA Special Needs Plans in rural areas, including ones in which the new SNPs might be competing against Universal American’s own MA plans. The insurer takes the actual risk, runs the insurance functions... Read more

Never Mind! MA 2014 Payment Rates Nightmare Ends…Sort of

By James Gutman - April 5, 2013 - Comments

Exactly 45 days after CMS’s preliminary 2014 payment notice sent Medicare Advantage plans into shock and depression, the agency’s final notice issued April 1 basically brought the coming pay rates back to something like the original expectations. Read more

Think You’ve Got Problems? Try Comparing Them With Universal Health Care’s

By James Gutman - March 29, 2013 - Comments

It just keeps getting worse for Universal Health Care Group, Inc. In the most recent development yesterday, federal agents raided the St. Petersburg, Fla., headquarters of the Medicare Advantage insurer that filed for Chapter 11 bankruptcy reorganization Feb. 6. The raid came just one week after a state circuit court judge ordered two major units of the company into receivership, followed by liquidation April 1, even though a unit of CarePoint Insurance Co. had won a bankruptcy court auction... Read more

Spending on Drugs, Use of Health Care Services Fell Last Year … But Is That a Good Thing?

By Angela Maas - May 17, 2013 - Comments

2012 saw some tremendous advances in drug development, notes a recently released study by the IMS Institute for Healthcare Informatics. At the same time, spending on drugs and the utilization of health care services declined nationwide. Read more

Obesity Drugs: More Than Just a Lifestyle Category?

By Lauren Flynn Kelly - April 25, 2013 - Comments

For the latest issue of Drug Benefit News, I revisit the obesity drug category in light of several developments that recently came to my attention. One is that Qsymia (phentermine and topiramate extended-release), which was approved in July 2012 and launched in September, just became available on a more widespread basis thanks to an amendment to its Risk Evaluation and Mitigation Strategy. This means we’re likely to see more direct-to-consumer advertising of this weight-loss drug very soon, one... Read more

Closing the Gap Between Pharmacy Services Valued and What Actually Are Provided

By Angela Maas - April 19, 2013 - Comments

Patient adherence to medication is one of the top concerns in the health care system today. Read more

Latest DBN Addresses Medication Adherence From Multiple Angles

By Lauren Flynn Kelly - April 11, 2013 - Comments

Last fall health policy institute NEHI issued an interesting paper called Thinking Outside the Pillbox: Improving Medication Adherence and Reducing Readmissions that suggested boosting compliance is a team effort that calls for “innovative models of discharge planning and follow-up care.” Jan Berger, M.D., chief medical officer at Silverlink Communications, Inc., is a big proponent of this idea and has suggested during many public speaking engagements that health plans, hospitals, PBMs and... Read more

Sequestration Cuts Already Are Impacting Health Care Stakeholders

By Angela Maas - April 5, 2013 - Comments

Only a few days after sequestration cuts were made, including a 2% cut to Medicare payments, a Washington Post article notes that “cancer clinics across the country have begun turning away thousands of Medicare patients.” To get their treatments, people are turning to other facilities such as hospitals — usually a much more expensive proposition. The cuts couldn’t have come at a worse time, as almost 250 U.S. Read more

Must CMS Move Mountains to Appease Members and Community Pharmacies? Maybe…

By Lauren Flynn Kelly - March 28, 2013 - Comments

In tomorrow’s issue of Drug Benefit News, I examine the debate over pharmacy access in Medicare Part D that was recently renewed by a letter to CMS from several members of Congress. At the center of their concern, of course, was the proliferation of preferred pharmacy networks, which incentivize members to use certain preferred (usually chain) pharmacies with lower copayments. Read more

Will Money Motivate More Fraud Tipsters?

By Francie Fernald - April 26, 2013 - Comments

The Center for Medicare and Medicaid Services is taking a cue from the generous whistleblower rewards that have prompted the rapid growth of False Claims Act cases alleging health care fraud and an Internal Revenue Service program designed to motivate individuals to report tax fraud, which has collected almost $1.6 billion and paid about $193 million in rewards over a five-year period. Read more

CMS Encourages Use of esMD in RAC Prepayment Therapy Reviews and Elsewhere

By Nina Youngstrom - April 16, 2013 - Comments

Outpatient physical, speech and occupational therapy providers that face recovery audit contractor (RAC) prepayment reviews can use the CMS Electronic Submission of Medical Documentation (esMD) program to get information on the status of the claims review, CMS says. Therapy providers also can submit additional documentation through esMD and the related “PWK” — paperwork for electronic data interchange — to the RACs and Medicare administrative contractors (MACs), Nancy Beckley, president of... Read more

The Part A/Part B Rebilling Dilemma: Withdraw Appeals or Wait It Out

By Francie Fernald - April 5, 2013 - Comments

Since the Centers for Medicare and Medicaid Services announced its major policy shift on payment for outpatient services after inpatient services are denied as medically unnecessary, hospitals have been regrouping and strategizing on how to take advantage of the policy shift. Read more

RACs Extend Prepayment Reviews to Outpatient Therapy

By Nina Youngstrom - March 26, 2013 - Comments

Recovery audit contractors (RACs) are spreading their prepayment-review wings, starting with outpatient physical, occupational and speech therapy provided in hospital outpatient departments, comprehensive outpatient rehab facilities and other outpatient settings that exceeds the $3,700 per beneficiary per year threshold. Until now, RACs have engaged in prepayment reviews of only MS-DRGs. In its March 22 announcement, CMS said there will be rehab prepayment reviews in 11 states and postpayment... Read more

New HIPAA Rule Has a Short Compliance Deadline and Lots to Do

By Francie Fernald - February 28, 2013 - Comments

Unless you’ve been living under a stone (although you may want to crawl under one about now), you know the final HIPAA/HITECH rule addressing the privacy and security of protected health information (PHI) is out and gives covered entities only six months to comply with its numerous changes. Perhaps most challenging in the short time period are the changes affecting business associates. Read more

Billing Under Wrong NPIs Leads to Settlement

By Nina Youngstrom - February 22, 2013 - Comments

Billing Medicare for services under the wrong physician names and National Provider Identifiers and submitting claims for nonphysician services under a physician’s NPI got an Alaska hospital in hot water with the HHS Office of Inspector General (OIG), underscoring all the different ways compliance can go awry. Bartlett Regional Hospital, an administrative division of the City and Borough of Juneau, agreed to pay $1.434 million for allegedly violating the civil monetary penalties law, according... Read more