Provider Contracting and Enrollment

Florida Governor Extends 30-Day Retroactive Medicaid Eligibility

The Governor of Florida has extended legislation reducing retroactive Medicaid eligibility from 90 to 30 days for another year. The bill also mandates the state Agency for Health Care Administration to submit a report to the legislature about the impact of the change on patients and health care providers by January 2020.

Illinois Physician Group Oppose Proposed Changes to State’s Nurse Practice Act

Seven organizations representing Illinois physicians and dentists, called the Preserve the Anesthesia Care Team, are protesting the proposed Illinois House Bill 2813, that if passed, would allow Certified Registered Nurse Anesthetists (CRNAs) to administer anesthesia without the physical presence of a medical doctor or dentist.

Pennsylvania Lawmakers Propose Bill Package to Combat Opioid Crisis

The Pennsylvania Senate has approved a package of bills to collectively combat the state’s heroin and opioid epidemic. The legislation includes seven bills, each designed to address specific issues and areas pertaining to opioid prescription and abuse.

Illinois Legislation Targets Medicaid Managed Care Claim Denials

The Illinois Legislature unanimously passed a health care reform package, which requires Medicaid managed care plans to pay claims within 30 days or face a penalty.

Aetna Makes Changes to National Precertification List

Effective September 1, Aetna will require precertification is required for certain new-to-market drugs.

UnitedHealthcare “Always Therapy” Code Reimbursement Error for Community Plan Claims

On May 21, UnitedHealthcare (UHC) discovered a claim edit was incorrectly loaded into its system. UHC is working to correct the error involving UHC Community Plan claims that included “Always Therapy” codes with and without the GN, GO or GP modifiers were denied for claims submitted on or after May 19, 2019.

Aetna Issues ASC and Ambulatory Payment Classification (APC) Code Edit Updates

Aetna has released updates regarding how the insurer will handle certain ambulatory surgical center (ASC) and ambulatory payment classification (APC) code edits under the ASC and APC payment methodologies.

Anthem Medical Non-Oncology Specialty Drug Review Changes

Anthem Blue Cross Blue Shield (Anthem) continues to streamline its medical specialty drug reviews by transitioning another drug review process from AIM to Anthem’s medical specialty drug review team. Beginning June 15, for all requests, regardless of service date, providers will need to submit a new prior authorization request by contacting Anthem’s medical specialty drug review team.

Anthem Announces Fee Schedule Changes

Anthem Blue Cross and Blue Shield (Anthem) recently notified members of the upcoming changes to its Anthem Plan Fee Schedules, scheduled to take place July 1.

White House Issues Executive Order on Healthcare Price Transparency

On June 24, the president signed an executive order on price transparency in health care that is intended to lower patient health care costs by providing prices for treatment prior to services being rendered.

CMS Looks at Revising HCAHPS Survey

In a notice to the Office of Management and Budget, CMS requested approval to collect public feedback on possible changes to the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS).

Supreme Court Rules Against HHS in DSH Payment Case

In a 7-1 decision, the Supreme Court ruled in favor of the nine hospitals that said the Department of Health and Human Services (HHS) violated the Medicare Act when it changed Medicare’s reimbursement adjustment formula for disproportionate share hospitals without providing notice and opportunity to comment.

CMS Finalizes Rule to Update and Modernize PACE

CMS has announced the release of a final rule designed to “update and modernize” the Programs of All-Inclusive Care for the Elderly (PACE) program, based upon best practices in caring for frail and elderly individuals.

Senate Health Committee Draft Legislation Targets Health Care Costs

Senate Health Committee leaders have proposed a legislative health care package which aims to reduce health care costs for individuals by addressing surprise medical bills, drug price transparency, and pharmacy benefit management.

CMS Final Rule Blocks States from “Diverting” Provider Medicaid Payments to Third Parties

CMS, in early May, released the Medicaid Provider Reassignment Regulation final rule removing a state’s ability to divert portions of Medicaid provider payments to third parties outside of the scope of what the statute allows. Under the rule, CMS is revoking the authority of states to “divert” certain Medicaid provider payments to a third party to fund other costs on behalf of the provider “for benefits such as health insurance, skills training, and other benefits customary for employees.”

CMS Finalizes Rule to Streamline Medicare Appeals Process

CMS has issued a final rule clarifies changes it has made to the appeals process in the Medicare program for providers, beneficiaries, and suppliers, and streamlines the process for Medicare Parts A and B claims appeals and for Medicare Part D coverage determination appeals.