Tagged with Medicare Advantage

DOJ v. UnitedHealth

The DOJ moves forward with legal action against two insurers accused of erroneous coding and inflated billing – UnitedHealth and WellMed Medical Management.

Humana to Exit ACA Exchanges by 2018

Humana has announced its plans to cease sales of individual health insurance plans through the ACA’s exchanges by 2018, potentially leaving more than 150,000 customers without a carrier.

CMS Finalizes New Rule to Reduce Medicare Appeals Backlog

In effort to reduce the significant Medicare appeals backlog, CMS finalized regulations for the Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures. According to HHS, the final rule streamlines administrative appeal processes, increases consistency in decision making across appeal levels, and improves efficiency for both appellants and adjudicators.

OIG Final Rule Expands Exclusion Authorities

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has issued a final rule expanding the authority to exclude individuals and entities from federal health care programs.

FL – Major Insurers Join New Value-Based Prescription Drug Model

Humana, UnitedHealthcare, WellCare, Blue Cross and Blue Shield of Florida and CVS Health are among those participating in a Medicare Part D model that gives insurers financial incentives to offer innovative programs that encourage patients to take their medications.

CMS Offers Revised Q&A for End of ICD-10 Grace Period

As of October 1, the year-long grace period for ICD-10 claims submissions has ended. To assist coders and hospitals, CMS has revised its Q&A “Questions and Answers Related to the July 6, 2015, CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities.”

Medicare Advantage: Positioned to Expand Rapidly?

Despite debates over Medicare Advantage (MA) costs and benefits vs. traditional Medicare, MA continues to expand. It continues to be attractive for insurers and is increasingly attractive to provider-sponsored plans. MA is expected to exceed 40% of Medicare within a few years.

Humana Updating Surgery Claim Processing Edits

Effective September 19, Humana will update claim processing edits for Surgery procedures, including: sigmoidoscopy, colonoscopy, other medical and surgical service during the postoperative period, FL Medicaid services included in delivery, birth center non-covered services, Florida Medicaid, and extracorporeal photopheresis.

Humana Updating Internal Medicine Claim Processing Edits

Effective September 19, Humana will update claim processing edits for Internal Medicine procedures, including: Sequential IV push, Telephone assessment and management, Home visit, Polysomnography, and Immune globulin.

UHC will Require CLIA Number on Laboratory Claims

Effective November 1, for participating providers and August 1, for non-participating providers, UnitedHealthcare will require CLIA Number on Laboratory Claims submitted on a CMS 1500 form or HIPAA 5010 837 P file.