Tagged with Medicaid Billing
Effective May 1, UnitedHealthcare (UHC) will deny any non-patient lab test claims submitted by hospital outreach labs if billed under the hospital’s facility participation agreement. The insurer is requiring that hospital outreach labs are credentialed and contracted as an independent reference lab in order to get their non-patient lab test claims paid.
CMS has announced its approval of Florida’s Section 1135 Medicaid waiver request, giving the state greater flexibility to respond to COVID-19. These increased flexibilities include the removal of service barriers; streamlining provider enrollment processes; allowing care to be provided in alternative settings; suspending certain nursing home screening requirements; and extending deadlines for appeals.
Pennsylvania has announced the state’s Medicaid program and Children’s Health Insurance Program (CHIP) will cover COVID-19 testing and treatment for beneficiaries when deemed necessary by a health care practitioner. Additionally, the state says it will also ease some prior authorization requirements to facilitate access to necessary testing and treatment.
Anthem Blue Cross and Anthem Blue Shield (Anthem) has developed a list of frequently asked questions regarding administrative processes and recent changes related to COVID-19.
CMS and the Department of Health & Human Services (HHS)’ Office of the National Coordinator for Health Information Technology have released two interoperability rules. The new rules aim to make it easier for patients to access and share their information and aim to end information blocking by requiring public and private entities to securely share health information with patients and penalize those who fail to do so.
CMS’ Center for Medicare and Medicaid Innovation is proposing a three-year extension for the Comprehensive Care for Joint Replacement (CJR) Model. The new rules proposes to change the definition of an episode to include outpatient hip and knee replacements as well as calculation modifications for the basis for the target price.
The U.S. Department of Health & Human Services (HHS) released the final version of its Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs. The strategy aims to reduce clinician burden through incremental changes that will push of electronic health record systems toward interoperability while easing regulatory burden.
The New Hampshire Joint Legislative Committee on Administrative Rules has approved changes to the state’s Medicaid to Schools program, which will allow eligible school districts to be reimbursed for providing health care, rehabilitation, and therapy services for children covered by Medicaid.
Ohio has released the recently revised definition of an Ambulatory Surgical Facility (ASF), as part of the new 2020/2021 general operating budget legislation. The change expanded the ASF definition, which may require some previously unlicensed facilities to obtain licensure.
CMS Administrator, Seema Verma, on February 11, announced the agency’s intent to reform prior authorization regulations later this year. According to Verma, the changes “will reduce administrative waste, increase patient safety and free physicians to spend time caring for their patients.”
New York Updates Quality Measures for Medicaid Managed Care Organizations in the Value Based Payment Program
The New York Department of Health released the 2020 value-based payment (VBP) Reporting Requirements Technical Specifications Manual for Measurement Year (MY) 2019. The report includes an overview of the specific quality measure reporting requirements for each VBP arrangement, as well as a description of the changes to the measure sets from 2018 to 2019.
On February 5, CMS released Part II of the Calendar Year (CY) 2021 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. In the CY 2021 Advance Notice, the agency is proposing updates and changes to the methodologies used to pay MA plans, Programs of All-Inclusive Care for the Elderly (PACE) organizations, and Part D sponsors.
On January 30, CMS announced the new Healthy Adult Opportunity (HAO) initiative that it will allow states to limit drug coverage under Medicaid without reducing manufacturer rebate obligations.
Florida Bill Would Require ‘Essential’ Providers to Contract with Medicaid Plans or Lose Supplemental Payments
The House Appropriations Committee on, February 5, approved HB 5201, a bill that, if finalized, would require “essential” providers to contract with all Medicaid managed care plans in their region or face the loss of supplemental payments.
Mental and behavioral health providers in Maryland are owed millions of dollars for services that have gone unpaid because of a malfunctioning state payment system. The Maryland Health Department has begun sending providers estimated payments totaling about $32 million per week until the system is fixed.
On January 17, CMS issued a memorandum providing additional guidance clarifying Medicare-Medicaid integration requirements for Dual Eligible Special Needs Plans (D-SNPs). The memorandum is intended to clarify distinctions between fully integrated D-SNPs (FIDE SNPs) and highly integrated (HIDE SNPs); permissibility of carve-outs of behavioral health services and long term services and supports (LTSS) for FIDE SNPs and HIDE SNPs; alignment of D-SNP and companion Medicaid plan service areas; and compliance with integration requirements for DSNPs that only enroll partial-benefit dually eligible individuals.
CMS, in December, announced ten states selected to receive funding under the Maternal Opioid Misuse (MOM) Model and eight cooperative agreements for the Integrated Care for Kids (InCK) Model, in seven states.
Ohio has announced that the state will transition to a single list of preferred Medicaid drugs, effective during the first quarter of 2020, in an attempt to streamline prior authorization and reduce confusion among beneficiaries, providers, and pharmacists.
Pennsylvania’s Medical Assistance Program implemented a statewide Preferred Drug List (PDL) effective on January 1, 2020. The PDL will be utilized by the fee-for-service program and all eight Medical Assistance (MA) managed care organizations (MCOs) in the state.
On October 9, the Department of Health and Human Services (HHS) announced proposed changes that seek to modernize and clarify the regulations that interpret the Physician Self-Referral Law (the Stark Law) and the Federal Anti-Kickback Statute. The proposed rule has been designed to provide greater certainty for healthcare providers participating in value-based arrangements and providing coordinated care for patients. The proposed changes are intended to ease the compliance burden for healthcare providers across the industry while maintaining strong safeguards to protect patients and programs from fraud and abuse.