Tagged with Provider Contracting and Enrollment
Federal Judge Overturns CMS Rule to Cut Medicare Payments to Outpatient Hospital Clinics
A U.S. District Judge has overturned a CMS rule that had reduced Medicare reimbursement rates for off-campus hospital clinic visits.
Improper Payment for Intensity-Modulated Radiation Therapy Planning Services
In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements. Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance.
Aetna National Precertification List Updates
Aetna has released the latest updates to its National Precertification List, scheduled to take effect this year through January 2020.
Anthem Blue Cross Blue Shield Clinical, Medical, and Coding Updates
Anthem BCBS has posted its recent Clinical, Medical, and Coding Updates, including revisions to Gene Therapy for Spinal Muscular Atrophy guidelines and changes to Positron Emission Tomography (PET) guidelines.
Cigna Preventive Care Services Policy & Precertification Updates
Cigna has made several additions and removals to its precertification list, as well as updates to its Preventive Care Services Policy.
UHC Updates Requirements for Specialty Medical Injectable Drugs
Effective October 1, 2019, Optum will make changes to and start managing prior authorization requests and processes for certain medical benefit injectable medications for UnitedHealthcare (UHC) commercial plan members.
New Jersey – UHC Outpatient Injectable Cancer Therapy Prior Authorization Requirement
Effective October 1, an affiliate company of UnitedHealthcare (UHC), will begin managing the insurer’s prior authorization requests for outpatient injectable chemotherapy and related cancer therapies for (UHC) Community Plan members in New Jersey.
Anthem Connecticut Introduces New Prior Auth Pass Program
Anthem is introducing a new program to reduce the administrative burden associated with current prior authorization (PA) processes for providers who are contracted with Anthem in Connecticut. The Prior Auth Pass Program allows providers who meet program requirements to waive prior authorization for select outpatient medical procedures that generally have high rates of PA requests and approvals.
Aetna Wisconsin Issues New Preapproval Requirements for Members
Effective July 1, Aetna will require prior authorization for certain procedures under its Enhanced Clinical Review Program with eviCore healthcare.
UnitedHealthcare Washington Changes in Advance Notification and Prior Authorization Requirements
UnitedHealthcare (UHC) Washington has released a notice detailing which procedure codes will require prior authorization for UnitedHealthcare Community Plan of Washington, effective for dates of service on or after October 1.
Humana Posts New, Revised Medical Coverage Policies
Humana has released its most recent medical coverage policy changes, including one new policy and updates to its brachytherapy, genetic testing, and transcatheter valve procedures policies.
Cigna Clinical, Reimbursement, and Administrative Policy Updates
Cigna has published a number of clinical, reimbursement, and administrative policy updates, including its reimbursement policy for spinal fusion related services, venous angioplasty, and orthotic prescriptions.
Anthem Posts Bundled Services and Frequency Editing Reimbursement Policies Updates
Beginning with dates of service November 1, Anthem will implement updates Bundled Services and Supplies and Frequency Editing reimbursement policies.
Aetna Issues New Radiation Therapy Preapproval Requirements
Beginning July 1, Aetna will require authorization for its enhanced clinical review program with eviCore healthcare for certain outpatient radiation therapy services.
CMS Notice on Bypassing Payment Window Edits for Donor Post-Kidney Transplant Complication Services
CMS has posted a notice for physicians, hospitals, and other providers billing Medicare Administrative Contractors (MACs) to ensure the payment window edits are bypassed when processing claims for donor post-kidney transplant complications services.
CAR T-Cell Cancer Therapy Available to Medicare Beneficiaries Nationwide
On August 7, CMS finalized the decision to cover Food and Drug Administration (FDA)-approved Chimeric Antigen Receptor T-cell (CAR T-cell) therapy, which is a form of cancer treatment that uses a patient’s own genetically-modified immune cells to fight disease. FDA-approved CAR T-cell therapies are approved to treat some people with specific types of cancer – certain types of non-Hodgkin lymphoma and B-cell precursor acute lymphoblastic leukemia.
CMS Issues Renewed Guidance to Ensure Medicaid Program Integrity
On June 20, CMS released a renewed guidance to state Medicaid agencies that outlines the necessary assurances that states should make to ensure that program resources are reserved for those who meet eligibility requirements.
CMS Releases 2018 ACA Risk-Adjustment Data
CMS, on June 28, released its report summary of the Affordable Care Act (ACA) risk adjustment program for the 2018 benefit year. The analysis found that 572 health insurers offering ACA plans participated in the program in 2018, and transfers between the companies totaled $10.4 billion.
CMS Issues FAQs on BPCI Advanced Model
CMS, on June 21, issued several new or updated frequently asked questions documents on the Bundled Payments for Care Improvement (BPCI) Advanced Model, an Advanced Alternative Payment Model launched last October that will run through 2023.
CMS Re-issues Memo to Providers about Emergency ‘Born-Alive’ Infants’ Rules
The CMS has re-issued a memorandum on emergency stabilization and treatment of newborn infants that could cause fresh anxiety for hospitals and physicians over abortion and care for pregnant women and severely disabled infants.
