From Inside Health Insurance Exchanges - With federal funding drained and enrollment levels lower than projected, state-based exchanges (SBEs) have boosted administrative fees, capped staffing levels and are introducing products to bring in new revenue. The Affordable Care Act (ACA) required SBEs to be self-sustaining by Jan. 1, 2015. HHS later said states could continue to draw down unused federal grant money to cover certain expenses. With those funds now depleted, or close to it, the remaining 13 state-based exchanges (SBEs) are on their own financially. Read more
From Health Plan Week - There is no hiding the fact health insurers are in a state of flux when it comes to strategizing over Affordable Care Act (ACA) exchanges. Major plans like UnitedHealth Group and Humana Inc. are exiting most marketplaces for 2017, and once staunch exchange supporter Aetna Inc. is rethinking its level of participation as the losses from individual policies grow to the hundreds of millions of dollars per year (story, p.… Read more
From AIS's Value-Based Care News - Accountable care organizations and patient-centered medical homes (PCMHs) increasingly are leveraging pharmacists to help manage their highest-risk patients, not just in an effort to reduce drug spending, but as a way to identify and mitigate pharmaceutical-based risk factors for adverse events. Pharmacists, either as ACO employees or independent partners, potentially can help root out polypharmacy, where the patient is taking multiple medications, or other high-risk factors, especially in the Medicare population. Read more
From Medicare Advantage News - As CMS carries out a new policy of reviewing Medicare Advantage plans’ entire provider networks for adequacy if they request service area expansions, MAN has learned that plans are dealing with a stricter-than-ever exceptions process and in some cases are having to drop legacy counties in order to expand. Read more
From Specialty Pharmacy News - As knowledge around biomarkers continues to grow, more tests identifying them are hitting the market. But rather than drilling down on only certain specific genes, some industry stakeholders maintain that a broader approach through a complete genomic profile, which allows for a more precise description of a person, is a more effective strategy for value-based medicine, particularly in oncology. Read more
From Report on Medicare Compliance - A Syracuse, N.Y., hospital has agreed to pay $3.2 million to settle false claims allegations that it used “unlicensed counselors” to treat psychiatric patients in crisis for a Medicaid program that reimburses hospitals $1,060 per visit, the U.S. Attorney’s Office for the Northern District of New York and the Attorney General of New York State said Aug. 1. St. Joseph’s Hospital Health Center allegedly violated “comprehensive psychiatric emergency program” (CPEP) regulations… Read more
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