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March 16, 2011

Today’s issue is brought to you by AIS's Report on Medicare Compliance, the nation's leading source of news and strategic information on Medicare compliance, Stark and other big-dollar issues of concern to health care compliance officers.

Today's Featured Story

With New Options for Whistleblowers, Compliant Processes Are the Best Strategy
Reprinted from Report on Medicare Compliance

The new climate for whistleblowers will spawn more False Claims Act lawsuits against health care organizations. But whistleblowers will have a hard time proving “reckless disregard” or “deliberate ignorance” — the standard of proof for the False Claims Act — if effective systems are in place that promote compliance with laws and regulations, said New York Medicaid Inspector General Jim Sheehan .... Read Full Story


From the AIS Blogs

Honey, I Shrunk the Provider Network

A growing number of health insurers are tinkering with their provider networks and are coming up with new products that offer lower premiums in exchange for more limited choices ... Read more


Quote of the Day

“What I find to be an extraordinary challenge is the immense variation between RFPs [related to contracts between PBMs and their plan sponsors] in terms of definitions or lack of definitions, particularly around financial sections. There are enormous differences as to what is asked for in contracts.”

— Helen Sherman, chief pharmacy officer of RegenceRx, the not-for-profit PBM of The Regence Group, told AIS’s Drug Benefit News.



Today's Datapoint

98% … of Medicare fee-for-service expenditures is what Medicare Advantage plans projected they would spend to provide Medicare’s standard benefit, based on 2010 MA bids, according to a new Government Accountability Office study.



Today from Washington

People on the Move

Lisa Johnson has been promoted to assistant vice president of the provider and member services contact center at Blue Cross Blue Shield of North Dakota. Johnson was manager of provider service....Catalent Pharma Solutions, Inc. appointed Lance Miyamoto senior vice president of human resources. Prior to operating his own consulting business, Miyamoto was an executive vice president at Comverse Technology Inc.


Today's Featured Health Business Job Opening

Spartanburg Regional - Regional HealthPlus
Medical Management Coordinator
Spartanburg , S.C.

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Upcoming Webinars

Social Media: How Insurers Can Strengthen Sales, Improve Member Health and Avoid Privacy Risks
Tuesday, March 22, 2011

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Beyond Buy and Bill: Managing Specialty Therapies Under the Medical Benefit
Tuesday, March 29, 2011

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Medical Homes: Health Plan Pilots that Have Improved Outcomes and Lowered Costs
Thursday, March 31, 2011

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New Reform-Driven Claims and Appeals Procedures: Practical Steps Plans Should Take Now
Tuesday, April 5, 2011

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CMS’s New Past Performance Assessment: Steps MA and Part D Plans Must Take Now to Avoid Harsh Penalties
Thursday, April 14, 2011

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Setting Out-of-Network UCR Rates: Evaluating FAIR Health’s New Benchmark Data and Other Alternatives for Insurers and Employers
Thursday, April 21, 2011

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Medicare Advantage Marketing for 2012: Steps to Take Now to Succeed Amid Reform-Driven Changes
Tuesday, May 10, 2011

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