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From Report on Medicare Compliance - Coding and coding audits may have been thrown a curveball by the 2017 update to the ICD-10-CM Official Guidelines for Coding and Reporting. Some coders think it could change the way diagnoses are pulled from physician documentation and put a wrench in clinical validation audits. The guidelines are written and revised annually by four organizations that hold tremendous sway over the hospital world: CMS, the American Hospital Association (AHA), the American Health Information Management Association (AHIMA) and the National Center for Health Statistics. Read more

From Health Plan Week - For private exchanges to accelerate the interest level of employers, both in the large and mid-size segments, health plans, benefits consultants and other operators must work across traditional and newer ancillary lines of the business, according to market consultants. Read more

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… 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 - At a recent meeting with 100 managers, the CEO of Presence Health in Chicago asked a regional compliance officer, Ahmed Salim, to walk them through the seven elements of a compliance program. The CEO had previously worked for an organization that was investigated by the government, so he had a visceral appreciation of compliance and wanted to ensure that Presence Health managers grasped the details. “That had a trickle-down effect,” Salim… Read more

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