Tagged with Provider Contracting and Enrollment

VT – ACO Pilot Project Announced

Vermont has entered into a one year agreement with OneCare to launch an ACO pilot program serving 30,000 Medicaid beneficiaries.

CMS Issues Non-ACA Compliant Plans Extension

CMS issued an insurance standards bulletin granting another extension to non-ACA-compliant health plans to allow insurers and consumers to extend for an additional year.

CMS Releases Medicaid Spending Report

According to the recently released annual report from CMS, in fiscal year 2016 states and federal government grew 4.3% to $575.9 billion and federal Medicaid spending grew 4.5% to $363.4 billion for the program to cover low income and disabled people. The report states Medicaid spending has increased in recent years and is expected to continue to rise, potentially reaching levels that could “displace spending on other important programs.”

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.

New Final Rule Targets Pass-Through Payments

CMS’ newest Medicaid managed care final rule will prevent increases in pass-through payments as well as the addition of new pass-through payments beyond those in place when the pass-through payment transition periods were established.

PA – New Global Capitation Model for Rural Hospitals

CMS has announced a new global capitation model for rural hospitals in Pennsylvania. Under the new model participating critical access hospitals and acute care hospitals will receive all-payer global budgets for a fixed amount of money that is set in advance and funded by all participating insurers, to cover inpatient and outpatient services.

UnitedHealth Group to Buy Outpatient Surgery Chain for $2.3 Billion

UnitedHealth Group has announced plans for its health services unit, Optum, to acquire Surgical Care Affiliates (SCA). Under the acquisition, Optum would add to its footprint SCA 205 surgical facilities, which SCA operates in partnership with thousands of surgeons in 33 states.

Study Finds New Payment Models May Potentially Reduce Health Care Disparities

A new study from Harvard Medical School claiming to have found “meaningful” improvements in quality, outcomes, and spending for all patients in the Alternative Quality Contract (AQC) between suggests binding insurers’ physician payments to quality metrics can narrow disparities between low- and higher-income patients.

Harvard Pilgrim Updates Eylea Medical Policy and 2017 Fee Schedule

Harvard Pilgrim has updated the Eylea Medical Policy to remove some codes that were not consistent with the policy’s intent and will now include ICD-10 codes newly released by CMS. In addition, the insurer says it will update its Standard professional fee schedule, incorporating recently released Medicare relative value units (RVUs) and laboratory rates for 2017.

Study Shows Surprise Medical Bills due to Excess Charges

Consumer Reports found 30% of patients with private insurance received a “surprise” medical bill from 2014 through 2015. According to a recent JAMA study, this is most likely due to the large number of physicians providing out-of-network services to a patient at an in-network facility and billing patients for the costs beyond what insurance will pay.