Entries in Thayer, Claire (163)

Friday
Apr282017

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

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Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

 

U.S. appeals court blocks Anthem bid to merge with rival Cigna

A U.S. appeals court blocked health insurer Anthem Inc's (ANTM.N) bid to merge with Cigna (CI.N) on Friday, upholding a lower court's decision that the $54 billion deal should not be allowed because it would lead to higher prices for healthcare. Reuters April 28, 2017

 

4 key questions surrounding Obamacare repeal

House Republicans are mounting yet another effort to tear down Obamacare and remake the health care system — but the path to delivering on one of the GOP's longest-standing priorities remains complicated and fraught with uncertainty. Politico April 27, 2017

 

Amid budget talks, White House says it will continue ACA subsidies

The White House on Wednesday pledged to continue payments critical to the success of Affordable Care Act exchanges, Politico reports. The pledge will come as a relief to insurers and providers after the administration’s earlier indication that it might withhold payments as a bargaining chip in this week’s budget negotiations.

Stat News April 26, 2017

 

PBM Express Scripts loses biggest client Anthem

Express Scripts said Monday that its biggest client, Anthem, will not renew its contract with the pharmacy benefit manager after the current agreement expires at the end of 2019.

Modern Healthcare April 24, 2017

 

Health Care In America: An Employment Bonanza And A Runaway-Cost Crisis

In many ways, the health care industry has been a great friend to the U.S. economy. Its plentiful jobs helped lift the country out of the Great Recession and, partly due to the Affordable Care Act, it now employs 1 in 9 Americans — up from 1 in 12 in 2000.

Kaiser Health News April 24, 2017

 

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

 
Thursday
Apr272017

What Goes into Combating Healthcare Fraud

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By Claire Thayer, April 27, 2017

According to the National Health Care Anti-Fraud Association, most health care fraud is committed by organized crime groups and a very small minority of dishonest health care provider. The NHCAA tells us that the most common types of fraud include:

·         Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.

·         Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).

·         Performing medically unnecessary services solely for the purpose of generating insurance payments.

·         Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs.

·         Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.

·         Unbundling - billing each step of a procedure as if it were a separate procedure.

·         Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.

·         Accepting kickbacks for patient referrals.

·         Waiving patient co-pays or deductibles for medical or dental care and over-billing the insurance carrier or benefit plan (insurers often set the policy with regard to the waiver of co-pays through its provider contracting process; while, under Medicare, routinely waiving co-pays is prohibited and may only be waived due to "financial hardship").

While the U.S. Department of Justice, FBI, CMS and other government entities are busy identifying and tracking down fraud schemes, Deloitte research points out that an emerging area of interest in health care fraud and abuse enforcement is that of relationship scrutiny.

This weeks’ edition of the MCOL Infographic, co-sponsored by LexisNexis, highlights some of the costs associated with fighting healthcare fraud:

(Click to View Full Size Image)

What goes into combating healthcare fraud?

(Click to View Full Size Image)


MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more
here.

 
Monday
Apr242017

6 Ways to Improve Your Member Communications

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 By Claire Thayer, April 24, 2017

Change Healthcare doubled member engagement for a regional health plan after introducing engagement best practices with a marketing mix that included email, blog posts, social media, a direct mail campaign, presentations to key group leaders and on-site workshops.

This special edition of the MCOL Infographic, co-sponsored by Change Healthcare, identifies 6 effective ways for health plans to improve communications with members:

 (Click to Enlarge Image)

(Click to Enlarge Image)

 

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

 

 
Friday
Apr212017

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

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Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

 

Lawmakers revisiting requiring those on Medicaid to work

A simple question — should adults who are able to work be required to do so to get taxpayer-provided health insurance? — could lead to major changes in the social safety net. AP News. Friday, April 21, 2017

 

How G.O.P. in 2 States Coaxed the Health Law to Success or Crisis

In Oklahoma, which has raged against the Affordable Care Act, insurance premiums are among the nation’s highest. New Mexico, which oversees its marketplace, has one of the lowest average premium costs. The New York Times. Friday, April 21, 2017

 

White House pressures GOP leaders on Obamacare showdown next week

A frantic and impatient White House is pressuring House GOP leaders for another showdown vote on repealing Obamacare next week so it can notch a legislative win before President Donald Trump’s first 100 days in office. Politico. Thursday, April 20, 2017

 

Sen. Grassley Demands Scrutiny Of Medicare Advantage Plans

Sen. Chuck Grassley (R-Iowa) wants federal health officials to tighten scrutiny of private Medicare Advantage health plans amid ongoing concern that insurers overbill the government by billions of dollars every year. Kaiser Health News. Tuesday, April 18, 2017

 

G.O.P. Bill Would Make Medical Malpractice Suits Harder to Win

Low-income people and older Americans would find it more difficult to win lawsuits for injuries caused by medical malpractice or defective drugs or medical devices under a bill drafted by House Republicans as part of their plan to replace the Affordable Care Act.

The New York Times. Saturday, April 15, 2017

 

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.

 

 
Friday
Apr142017

Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Untitled 1
 

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

 

Bipartisan Senate Bill Takes Step Against Opioid Epidemic

Morning Consult reports: A bipartisan Senate bill unveiled Thursday would impose strict limits on some opioid prescriptions, a small tweak to federal law that is part of an ongoing effort in Congress to curb overuse of the drugs. Morning Consult. Thursday, April 13, 2017

 

States Moving More Medicaid Patients To Managed Care

Private health insurance companies stand to reap a bigger share of the Medicaid business as states deal with budget shortfalls and increased spending on medical care. Forbes. Thursday, April 13, 2017

 

Trump Signs Law Giving States Option To Deny Funding For Planned Parenthood

President Trump quietly signed legislation Thursday that rolls back an Obama-era rule protecting certain federal funds for Planned Parenthood and other organizations that provide legal abortions. NPR. Thursday, April 13, 2017

 

Trump administration issues final rule on stricter Obamacare enrollment

The Trump administration on Thursday issued a final rule that will shorten the Obamacare enrollment period and give insurers more of what they say they need in the individual insurance market, likely making it harder for some consumers to purchase insurance, healthcare experts said. Reuters. Thursday, April 13, 2017

 

Repeal, Replace … Revise: Your Guide To How A Trump Proposal Might Change ACA Insurance

Repeal and replace is on-again, off-again, but that doesn’t mean the rules affecting your insurance will remain unchanged. The Trump administration’s proposed rule aimed at stabilizing the health law’s insurance marketplace could have rapid, dramatic effects on people who do not get insurance through work and buy it on the Affordable Care Act’s exchanges. Kaiser Health News. Thursday, April 13, 2017

 

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.