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 5, 2018 | Home Health, Infusion, Post-Acute Care
CMS finalized a 2.2% CY 2019 rate update to home health payments and the transition to a revised payment system for CY 2020, largely following the proposed approach, as well as the policies for the temporary home infusion transitional benefit, again following the proposed approach. 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.
Oct 31, 2018 | Legislation/ Budgets/ Macro
The 2018 mid-term election is very likely to have a neutral outcome for the healthcare sector. The most likely outcome is divided government that engenders legislative stalemate and thus shelters current levels of federal healthcare spending. The low-probability negative scenario is Republicans maintaining control of Congress and returning to efforts to reform Medicaid and reduce federal Medicaid spending. Click to read more.
Oct 30, 2018 | Drugs, Legislation/ Budgets/ Macro, Medicare, Products
This past week, President Trump and HHS Secretary Azar outlined a potential reform package aimed at lowering the price of Part B drugs. The proposal would tie Medicare Part B drug prices to a lower international pricing index rather than ASP, and replace the 6% add-on for physicians with fixed payments that remove the incentive to dispense higher priced drugs. This brief outlines the proposal, and discusses the potential timing of such reforms. Click to read more.
Oct 29, 2018 | Legislation/ Budgets/ Macro, Medicare
The Office of Information and Regulatory Affairs recently released the Administration’s Unified Agenda of Regulatory and Deregulatory Actions, which reflects agencies’ foci. We compiled a list of key items in the healthcare space by date of anticipated rule release. Click to read more.
Oct 26, 2018 | Managed Care Friday
1. 380,000: The number of premature births a year or about 10% of the US births, according to a Cigna source we interviewed who says the managed care plan is improving coverage and reimbursement for ultrasonagraphy in the first trimester, particularly for those women unclear about the timing of their menstrual cycle. 2. AIM Higher, Radiation: In 2019, new approval rules will take effect for radiation oncology, and most ease some of the existing requirements, which would be a plus for providers in states where Anthem is the major payer. AIM, the Anthem company that determines clinical...
Oct 25, 2018 | Medicare Advantage, Payers
HHS’s oversight office found that Medicare Advantage (MA) organizations overturn denials of health services at high rates upon appeal, indicating potential issues with MA coverage determinations and CMS’s processes to ensure plan compliance. Click to read more.
Oct 19, 2018 | Managed Care Friday
Extra Point Managed care plans and healthcare providers have been struggling of late to make value-based payments work, but this may be changing. Payers in more than 6 states serving Medicaid patients are now being told from the state that 25% of their premium must be spent on value and, under contracts with the state, 33% up to 50% in the near future, our sources say. But this isn’t so clear to define. Thankfully, a few of the MCOs, and a few in other managed Medicaid states we’ve interviewed, say they think the states will give them ‘wiggle room’ to define value on their terms. One...
