Nov 16, 2018 | Managed Care Friday
1. 181%: Rise in total ER costs in the last few years according to a Blue Texas study of its membership. The increase correlates in part to the rise in freestanding ERs in this state. Blue TX is taking on more of an effort to do claims reviews to manage claims – described to us as a soup to nuts review for HMO patients using OON ERs. The plan is going to be ‘holding the claim requesting medical records, checking the bill to make sure that’s what happened in ER matches the record, and combing the record to assess patient history and whether the patient’s decision to go to the ER was what a...
Nov 9, 2018 | Managed Care Friday
1. 511: In our poll of 511 primary care providers with board certification in geriatric medicine, a startling 84%, up slightly from last year, said that physical therapy services for seniors are likely unnecessary or at least need deeper evaluation to determine whether the patient has other comorbidities or causes of pain, such as substance abuse, dehydration, untreated PTSD or depression, or a sedentary lifestyle. 2. GI Bundle, With A Twist: A health plan in the east has created an episodic payment model for those treating Crohn’s disease. Payment includes behavioral health treatment for...
Nov 8, 2018 | Medicare, Physician Fee Schedule, Physicians
CMS has finalized the CY 2019 Physician Fee Schedule (PFS). The update for 2019 is +0.11%. The most significant policy in the rule is that proposed revisions to E/M coding are not finalized for 2019. A less impactful version is tentatively established for 2021, but is subject to further modification based on AMA recommendations. Click to read more.
Nov 1, 2018 | Medicare Advantage, Payers
CMS revisited its stalled 2012 methodology for extrapolating the results of risk adjustment data validation audits to contract-level recoveries of improper payments. Click to read more.
