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April 11, 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

Medicare Value-Based Purchasing Opens A Large New Can of Compliance Worms
Reprinted from Report on Medicare Compliance

Hospitals face a new set of fraud-and-abuse risks as value-based purchasing gets underway in a few months. For the first time, CMS will link payments to patient outcomes and satisfaction in all Medicare acute-care hospitals, which is a big step beyond Medicare quality reporting. As a result, hospitals will share more information and require greater physician cooperation, and that could spell trouble if not handled with care .... Read Full Story


From the AIS Blogs

CMS Says Provenge Coverage Is ‘Reasonable and Necessary’ for Certain Prostate Cancer Patients

In a much-awaited decision, CMS has issued a proposed decision memo on Medicare coverage of the prostate cancer therapy Provenge. Based on clinical trial data for the autologous cellular immunotherapy treatment, CMS says that “the evidence is adequate to conclude” that on-label use of the therapy — also known as sipuleucel-T — is “reasonable and necessary.”... Read more


Quote of the Day

Medicaid “is definitely not a place where you can just impose rules about what you will and won’t pay for and trust that to drive savings. Managed care companies need to figure out the specific care needs of the populations they are covering and build a care and support model that will effectively lower cost for this population.”

— Jim Fields, an associate partner at the management consulting firm of Oliver Wyman, told AIS’s Health Plan Week.

Click here to read the HEALTH PLAN WEEK article in which this quote appeared. (Free for HPW subscribers; $17 for non-subscribers).


Today's Datapoint

$4 … generic drugs could generate $5.8 billion in savings, according to research by the University of Pittsburgh Graduate School of Public Health that appeared in the March 14 issue of Archives of Internal Medicine.



Today from Washington

People on the Move

Patriot National Insurance Group appointed Robert Zamary senior vice president of client enterprise services. Zamary was vice president of claims at Patriot Risk Services....Kimberly Ovitt has been named senior vice president of public relations at St. Jude Children's Research Hospital. Ovitt was director of communications at Arizona State University.


Today's Featured Health Business Job Opening

Presbyterian Health Plan
Director, Provider Reimbursement
Albuquerque, N.M.

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Upcoming Webinars

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

Click here for details.

Outcomes-Based Contracts: Innovative Payer Deals to Improve Member Health and the Bottom Line
Tuesday, April 19, 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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New ACO Regulations: Discover the Opportunities and Pitfalls Ahead
Thursday, May 5, 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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Payer Strategies to Manage High-Cost Specialty Drugs That Will Hit the Market Soon
Thursday, May 12, 2011

Click here for details.

A Practical Guide to Federal Medical Loss Ratio Requirements
AIS's Health Business Daily