AIS Blogs | AIS Health

Romneycare Comes Full Circle With Mass. Legislation to Curb Health Spending

By Jonathan Block - May 11, 2012 - Comments

Massachusetts made headlines this week, and it's because of its former governor and presumptive Republican presidential nominee Mitt Romney. The reason? The state Senate May 9, following in the footsteps of their colleagues in the House, introduced a bill that aims to curtail the rise in medical spend by targeting providers and payors. Read more

Did Dire Warnings on HIPAA 5010 Compliance Actually Come True?

By Jill Brown - May 4, 2012 - Comments

There must have been a certain amount of schadenfreude among providers watching Health Net, Inc. report a $27 million first-quarter 2012 loss, triggering a 25% drop in its share price. After all, Health Net attributed blame for its woes partly on an inability to comply with updated 5010 electronic transaction standards under the Health Insurance Portability and Accountability Act (HIPAA). When CMS set a Jan. Read more

Insurers Are Learning That Games Are No Longer Child’s Play

By Jonathan Block - April 27, 2012 - Comments

Your kids may be the ones playing with a PlayStation, Xbox or Wii, but soon you might find your insurance company encouraging you to use a video game system. While this may sound like a prescription to turn members into couch potatoes, the reality is that insurers are just beginning to grasp the idea of gamification to encourage members to do desired activities, whether it’s exercising or reminding them to get a lab test done. Read more

Have Your Say on Pay

By Jill Brown - April 16, 2012 - Comments

To judge from CEO compensation, which remains at healthy levels, according to Health Plan Week's annual survey, publicly traded health insurers have not been cowed by the “say on pay” provisions of the Dodd-Frank Wall Street Reform and Consumer Protection Act. But insurers aren’t ignoring the rules, either. 2012 marks the second year that shareholders have the chance to have their say on pay. Read more

The Firing of CEO Ken Melani and the Impact on Highmark’s Future

By Jonathan Block - April 2, 2012 - Comments

While much of the country last week was focused on the oral arguments before the Supreme Court on the health reform law, the Pittsburgh area found itself enthralled in a whole other argument that involved the CEO of a major health insurer. Exactly a week after CEO Ken Melani was allegedly involved in an altercation with the husband of his mistress — whom he personally also hired allegedly a few weeks before the affair began— and charged with assault and trespass, Melani was shown the door by... Read more

The Supreme Court Cases and the Potential Impact on Health Insurers

By Jonathan Block - March 20, 2012 - Comments

A big event takes place later this week when the Affordable Care Act marks its two year anniversary on March 23 since it was signed into law. Since then, many changes have taken place (with many more to come) that have impacted the health insurance industry dramatically. But don’t expect President Obama to be celebrating on Friday. Read more

‘Say It Ain’t So’: Has Politics Crept Into the MLR Rebate Rule?

By Patrick Connole - May 17, 2012 - Comments

Washington pundits like to call the presidential campaign season the “silly season,” referring to the fact every move made by a candidate, or, in this case, a candidate’s administration, comes under intense scrutiny for how it reflects on a bid to obtain or keep the keys to the White House. A number of health reform law experts, as you can read in a May 21 article in Health Reform Week, don’t use the word “silly” to describe one element of the newly released final HHS rule on the medical loss... Read more

Employers Could Save Billions by Dropping Coverage. But Will They Do It?

By Steve Davis - May 9, 2012 - Comments

A report released this month by the House Ways and Means Committee is 100% correct: Large employers would save billions of dollars over the next decade by eliminating health coverage for their employers and instead paying a $2,000 per-employee penalty. But employee benefits consultants doubt many, if any, big employers will make such a bold move. Why? Employers have been voluntarily offering health benefits to employees since the end of World War II. And they continue to do so, despite the ever... Read more

Should ACO Developers Form Limited Liability Companies?

By Jennifer Lubell - April 26, 2012 - Comments

In its decision to participate in the Medicare Shared Savings Program (MSSP) as well as invest in bundled payments and a clinically integrated network in the commercial sector, Cincinnati health system Mercy Health thought it would be prudent to form a limited liability company, or LLC. Establishing a new corporate entity, a wholly owned subsidiary known as Mercy Health Select LLC, offers Mercy Health with more legal flexibility to engage in ACO-type models, Paul Hiltz, the LLC’s president,... Read more

Is UnitedHealth Gearing Up for Reform?

By Jennifer Lubell - April 24, 2012 - Comments

UnitedHealth Group has been racking up acquisitions of Medicare Advantage (MA) plans, not to mention several contract awards that previously belonged to Blues plans. As one health care observer explains, larger plans like United are seeking to expand their presence nationally, to prepare for whatever happens with health reform. Read more

Can Frustration Over Rate Hikes Translate to Members for CO-OPs?

By Steve Davis - April 23, 2012 - Comments

Last week, I moderated a panel discussion on Consumer Operated and Oriented Plans — better known as CO-OPs. The health reform law envisions that at least one CO-OP will operate in every state and compete against the established insurance companies. But despite the administration’s backing — and $3.8 billion in low-interest loans — pitting these start-ups against industry behemoths seems like holding a scrimmage between my four-year-old’s tee-ball team and the Washington Nationals (this year’s... Read more

MSSP: Off to a Good Start?

By Jennifer Lubell - April 11, 2012 - Comments

The cloud of uncertainty that hangs over the federal health reform law in the Supreme Court wasn’t about to dampen Jonathan Blum’s good mood when he announced that 27 organizations had signed up for the Medicare Shared Savings Program (MSSP) — with hundreds more waiting in the wings to join its ranks. Blum, CMS’s deputy administrator and director of its Center for Medicare, asserted during an April 10 conference call that the program was off to a “phenomenal” start. Read more

Waiting for Employers: Is the Train Finally Leaving the Station?

By James Gutman - May 18, 2012 - Comments

It has been an article of faith, but now it may finally become an article of fact. Employers that still offer retiree medical benefits — a vanishing but not yet vanished breed — seem at last to be doing what the Medicare health plan industry has been predicting for years. They are, in growing numbers, shifting post-age-65 retirees who have company medical benefits to Medicare Advantage (MA) and stand-alone Prescription Drug Plans (PDPs). Some of the evidence comes from first-quarter financial... Read more

Requiem for an Earnings Reporting Season

By James Gutman - May 11, 2012 - Comments

For those of us crazy enough to listen to all the quarterly earnings calls of publicly held Medicare Advantage and Part D plan sponsors, there always are a few "rewards" in the form of especially quotable remarks of company executives. And the just-completed first-quarter 2012 round of calls was no exception. Read more

Putting a New Face on Medicare Advantage Beneficiaries

By James Gutman - May 4, 2012 - Comments

Let it not be said that the health insurance industry is easing off the throttle in its campaign to save Medicare Advantage plans in the coming battles on what to cut when it's time to slash the federal budget deficit. The newest evidence of this campaign is a report put out by the America's Health Insurance Plans trade group May 3 showing the high proportions of minority groups and very low incomes among seniors who enroll in MA plans. Read more

One Year Later, Has WellPoint Solved Its MA Problems?

By James Gutman - April 27, 2012 - Comments

By now, the basic details of WellPoint, Inc.’s 2011 Medicare Advantage debacle are known. The company made its regional MA PPO too attractive for high-cost seniors, especially in Northern California, and wound up with huge claims that translated into huge losses and a medical loss ratio (MLR) above 100%. Read more

In MA and Part D Marketing, Here's What Not to Say

By James Gutman - April 20, 2012 - Comments

If Medicare Advantage plans sometimes wonder why CMS puts so much emphasis on marketing surveillance and compliance, they may have gotten the answer in a presentation by a CMS official at the agency's 2012 MA and Part D spring conference in Hunt Valley, Md., April 12. Read more

How to Confuse MA Plans Without Really Trying

By James Gutman - April 13, 2012 - Comments

Everything about CMS's new policies regarding Medicare Advantage plans' quality programs seems born out of good intentions and concepts. But the initial results of the policy changes, at least judging from questions and comments at the CMS MA and Part D spring conference in Hunt Valley, Md., this week, seem to be confusion and anxiety. Read more

Bridging the Communication Gap

By Angela Maas - May 18, 2012 - Comments

With health insurers looking for ways to save money, more and more of them are focusing on drug outcomes, using those data to drive coverage decisions. But getting that information may be easier said than done. In the more than seven years I’ve been writing Specialty Pharmacy News, there has always been discussion about communication gaps among the various pharma stakeholders. But the one that seems the most baffling is that between insurers and pharma manufacturers. Read more

Are Generic Drug Discount Programs Messing With Adherence Measurement?

By Lauren Flynn Kelly - May 10, 2012 - Comments

Medication adherence is one of those inescapable topics when it comes to covering pharmacy benefits and something that continues to plague health plan pharmacy directors as they implement programs to improve outcomes and control costs. According to Express Scripts Holding Co.’s 2011 Drug Trend Report, failure to take medications as prescribed cost the U.S. $317 billion in 2011. Read more

PCORI Is Set to Issue Final Priorities and Research Agenda

By Angela Maas - May 3, 2012 - Comments

The Patient-Centered Outcomes Research Institute (PCORI), mandated by the health reform law, has been working on its priorities and research agenda and expects to release the final version on May 21. During a Journal of the American Medical Association media briefing on April 17, Anne C. Beal, M.D., PCORI’s chief operating officer, explained that the organization “helps support comparative-effectiveness research [i.e., CER]” not only “in terms of prioritizing research but also synthesizing”... Read more

Prescribers’ Efforts Are Being Wasted, but Are Prescribers Creating Waste, Too?

By Lauren Flynn Kelly - April 26, 2012 - Comments

Express Scripts’ recently released 2011 Drug Trend Report estimates the amount of waste associated with suboptimal pharmacy-related behavior by U.S. consumers was $408 billion. That’s partly due to mix waste and channel waste, but mainly stems from patients not taking their meds. But what about waste pertaining to unnecessary treatments? Earlier this month, the ABIM Foundation made headlines with its Choosing Wisely initiative, which empowers patients and physicians with a list of 45 items that... Read more

How Much of an Impact Is the Express Scripts/Medco Deal Having on the PBM Marketplace?

By Angela Maas - April 19, 2012 - Comments

Yesterday SXC Health Solutions announced its intention to purchase Catalyst Health Solutions. The deal comes just a couple of weeks after the FTC’s approval of Express Script’s purchase of Medco Health Solutions, which formed the largest PBM in U.S. Read more

How Will The Newest Mega Merger Impact Medicare Part D?

By Lauren Flynn Kelly - April 12, 2012 - Comments

As we watch the dust settle from the recent acquisition of Medco Health Solutions, Inc. by Express Scripts, Inc. (ESI), multiple questions will arise for current and prospective clients as well as PBM competitors. Will it create enough marketplace disruption to have a positive impact on smaller PBMs, as it did while the deal was pending? What will formularies look like once they are integrated? What will become of Walgreen Co.’s current contracts with the Medco book of business? One question... Read more

A Lot Is on the Line for Hospitals When the VBP Program Kicks In

By Francie Fernald - May 17, 2012 - Comments

FY 2013 is the first year hospitals will deal with the reimbursement impact of the Hospital Value-Based Purchasing (Hospital VBP) program. CMS will compare a hospital’s score on certain measures to a baseline standard and calculate an incentive payment for hospitals that meet or exceed the baseline. The upside is a hospital could be paid more than it would have been paid under the standard MS-DRG payment methodology for the admission; the downside is it may be paid less. CMS will fund the... Read more

IG Levinson Suggests Monthly Exclusion Checks, Says Exclusion Guidance Is Coming

By Nina Youngstrom - May 7, 2012 - Comments

HHS Inspector General Dan Levinson emphasized the importance of the compliance officer’s independence from internal counsel during remarks April 30 at the Health Care Compliance Assn.’s annual Compliance Institute. As health care organizations tackle complex issues, there should be some separation between compliance and legal. “If I am a board member, it is helpful to go to the chief legal officer and say, ‘it is defensible?’ And then go to the chief compliance officer and ask, ‘is it right?’... Read more

CMS Has Posted the FY 2013 Proposed IPPS Rule: Here’s the Good News

By Francie Fernald - April 26, 2012 - Comments

No doubt you are aware that CMS has posted the proposed FY 2013 Inpatient Prospective Payment Rule for review and comment (comments are due by June 25; Federal Register publication is scheduled for May 11). Perhaps the best news is that this year the scramble to update systems with new ICD-9-CM codes, changes to MCCs and CCs, and revisions to the MS-DRGs won’t happen because CMS imposed a freeze on revisions to the codes to accommodate the implementation of ICD-10 on Oct. 1, 2013. Read more

The ICD-10 Delay Is Official…and It’s Expensive

By Francie Fernald - April 10, 2012 - Comments

The rulemaking released yesterday by HHS contained four different initiatives, which are, at best, somewhat related. The most newsworthy of the four was the proposed delay of ICD-10 to Oct. 1, 2014. The other three proposals would establish (1) a unique health plan identifier as required by HIPAA for electronic health care transactions; (2) a data element to identify other entities that are not health plans, health care providers, or individuals, but that need to be identified in standard... Read more

Risk of Double Payment Is Reason for No Appeals Under Rebilling Demo

By Nina Youngstrom - April 6, 2012 - Comments

Some hospitals have quit the recovery audit contractor (RAC) rebilling demonstration program, CMS and hospitals say, apparently because they are frustrated they had to relinquish appeal rights and/or didn’t understand the implications of this and other aspects of the demonstration. The Part A-to-Part-B rebilling demonstration allows participating hospitals to resubmit claims for allowable Part B payment after an auditor has determined that the Medicare beneficiary met the requirements for Part... Read more

RAC Stats for 4th Quarter 2011 Show Financial Impact on Providers

By Francie Fernald - March 22, 2012 - Comments

The benefit of the Recovery Audit Program to the government and its impact on health care providers continues to be evident, based on reports from CMS and the American Hospital Association on activity during the fourth quarter 2011. The CMS Quarterly Newsletter reported overpayment collections of $397.8 million and the return of $24.9 million in underpayments. Read more