85% medical-loss ratio in final managed Medicaid rule

The CMS has finalized a long-awaited rule that will overhaul managed Medicaid, which has not been updated in a decade.

The sweeping 1,425-page rule, which was proposed last May, caps insurer profits, requires states to more rigorously supervise the adequacy of plans’ provider networks, encourages states to establish quality rating systems for plans, allows more behavioral healthcare in institutional settings and promotes the growth of managed long-term care. But the CMS deferred to state control for several issues.

States have turned to Medicaid managed-care plans to cut costs and gain more budget predictability. But some charge that leads managed Medicaid insurers to offer inadequate provider networks and deny needed care to pad their bottom lines. Connecticut has actually reverted back to traditional fee-for-service Medicaid, saying it abandoned the managed-care version because it did not save money or improve care.

Thirty-nine states and the District of Columbia outsource their Medicaid programs by paying monthly fixed, per-member sums to private insurers, according to HHS. Approximately 46 million low-income people were enrolled in a managed Medicaid plan in 2015, consulting firm Avalere Health reports, and that number continues to rise. The Affordable Care Act’s Medicaid expansion has also funneled more beneficiaries in managed-care plans.

One of […]

By |May 1st, 2016|Medicare/Medicaid|Comments Off on 85% medical-loss ratio in final managed Medicaid rule

Healthcare providers take heat over debt collection lawsuits against patients

With surprise medical bills and high out-of-pocket costs getting increasing political attention, some hospitals and physician groups are drawing criticism for aggressive collection actions against patients.

A St. Louis Post-Dispatch investigation last week found more than 1,000 debt collection lawsuits between Dec. 2, 2014, and March 10, 2016, in the St. Louis area stemming from emergency department treatment provided by the Schumacher Clinical Partners medical group at hospitals owned by the not-for-profit SSM Health, a Catholic system. The suits were filed by Capio Partners, a large national medical debt collector that bought unpaid ED bills from Schumacher in 2014.

The article cited the case of an uninsured woman who was treated in 2011 at an SSM hospital’s ED and who said she was told she wouldn’t be billed. Then she found herself being sued last year over a $1,183 bill. When she tried to get her hospital record to figure out the cost of her visit, the hospital told her it couldn’t process the request without an exact date.

Under the Affordable Care Act and a 2014 Internal Revenue Service rule, not-for-profit hospitals are required to provide financial assistance to qualifying low-income patients and avoid using extraordinary collection practices against these patients. […]

By |May 1st, 2016|Collections, Industry News|Comments Off on Healthcare providers take heat over debt collection lawsuits against patients

Will Medicare’s physician payment overhaul drive more docs to hospitals?

The CMS on Wednesday began to answer some of the many questions about how physicians will get paid under the Medicare Access and CHIP Reauthorization Act. But some stakeholders were immediately dissatisfied with what they saw, and the 963-page rule may have raised as many questions as it answered.

The rule provided more clarity around the CMS’ proposed Quality Payment Program, which consolidates three existing payment models: the Physician Quality Reporting System, the Physician Value-based Payment Modifier and Medicare’s incentive program for achieving meaningful use of electronic health records.

Agency officials said the new consolidated program will offer physicians greater simplicity and flexibility, providing two paths for physician payments when it goes into effect in 2019. Physicians can choose to participate in the Merit-based Incentive Payment System, or MIPS, or have a significant amount of their revenue generated under a qualifying Alternative Payment Model, or APM.

The CMS expects that, in the first program year at least, most physicians will choose the MIPS path. Physicians will select six outcomes-oriented measures to track, and the budget-neutral program will carry upside and downside risk.

The APM path will reflect traditional Medicare payments in its first two years and then will be opened to all payers, […]

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