Dec 7, 2018 | Managed Care Friday
1. 4: The number of vitamin D tests you can do per year, starting in January, if treating United California Medicaid patients with certain conditions, as a result of what the plan calls ‘recent clinical evidence about the test’. We would not be surprised to see this policy find its way into United coverage policies beyond California. 2. Homeless Healthcare: One woman’s story chronicles the positive impact of a program in Massachusetts designed to address gaps in care for this population: click here 3. Sound Off--Sorry Moms: United’s Community plan for Medicaid patients will no longer...
Nov 30, 2018 | Managed Care Friday
1. 41: The percentage of parents in our poll who said they are hiring a home health aide for their mom or dad to help prevent another fall. Falls have increased in New England (during the winter months ), largely due to dehydration, lack of a consistent diet, orthostatic/BP issues, and a range of dementia or psych influences, parents said. Of those hiring an aide, 46% said their mom or dad has a Medicare Advantage plan with Humana, United Healthcare, or BCBS, though nearly all (90%) said they aren’t sure what if any of these aide services are covered by insurance. About 85% of those hiring...
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...
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 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...
