Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Federal Regulation

BCBS of TN Defrauded $174M in $2B Telemedicine Insurance Scheme

October 18, 2018 - BlueCross BlueShield (BCBS) of Tennessee has been named a damaged party after it was defrauded $174 million as part of a larger $2 billion telemedicine insurance scheme, according to the Department of Justice (DOJ). The District Court for the Eastern District of Tennessee unsealed a 32-count indictment that alleges four individuals and seven healthcare companies attempted to commit...


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AMA, Industry Orgs Object to Short-Term Health Plan Expansion

by Thomas Beaton

The American Medical Association and other industry trade groups have filed amici curiae in support of a lawsuit contesting the legality of short-term health plans. The Association for Community Affiliated Plans (ACAP) contends that the...

FDA Recruits Payers to Submit Quality Feedback on Medical Devices

by Thomas Beaton

FDA has launched a new quality assurance program that leverages feedback from commercial payers about medical device coverage requirements in order to expedite approvals. The Private Payor Program (PPP) is a voluntary program for medical...

MedPAC to Explore if Hospital Consolidation Impacts Medicare Costs

by Thomas Beaton

The House Committee on Energy and Commerce has asked the Medicare Payment Advisory Commission (MedPAC) to investigate whether or not hospital consolidation increases Medicare spending. In a letter to MedPAC, Representatives Greg Walden...

Handful of States Propose Lower ACA Premium Rates for 2019

by Thomas Beaton

Several states have announced lower ACA premium rates for 2019, bucking a national trend brought on by unstable markets and regulatory changes.   While early proposals from a number of states, including Virginia, Maryland, and...

Payers Sue to Collect 2017 Cost Sharing Reduction Payments

by Thomas Beaton

Payer organizations are exercising their right to use the court system to collect cost sharing reduction (CSR) payments that were not provided in the last quarter of 2017. A number of lawsuits are challenging the government’s...

GOP Senators Propose to Reinforce Pre-Existing Condition Protections

by Thomas Beaton

Half a dozen Republican Senators have introduced a bill that would ensure the Affordable Care Act’s pre-existing condition protections would remain a federal law despite upcoming legal challenges. The Ensuring Coverage for Patients...

GAO Critiques HHS Actions on ACA Navigator Program Funding

by Thomas Beaton

The Government Accountability Office (GAO) has questioned the data-driven methodology behind significant reductions in funding for the ACA navigator program and subsequent declines in new enrollment in health insurance plans.   In a...

1115 Medicaid Demonstrations Should be Budget-Neutral, CMS Says

by Thomas Beaton

CMS has issued new guidelines for state officials around creating budget-neutral 1115 Medicaid demonstrations. CMS informed state governments that the agency will use a formalized methodology to determine if 1115 demonstrations are a...

CMS Provides $8.4M to Stabilize State Insurance Markets

by Thomas Beaton

CMS has awarded $8.4 million to 31 states in an effort to stabilize state insurance markets and increase the number of affordable health plan options for beneficiaries. Recipients are allowed to use the ACA-funded State Flexibility Grant...

New Jersey Gains CMS Approval for Reinsurance Program

by Thomas Beaton

New Jersey has received approval from CMS to implement a five-year reinsurance program that aims to lower individual health plan premiums by 15 percent. The program will operate from 2019 to 2023 and provide $218 million in reinsurance...

CMS Processes State Medicaid Requests, Approvals 23% Faster

by Thomas Beaton

CMS has announced that an agency initiative to streamline state Medicaid approvals and state plan amendments (SPAs) has increased approval processing speed by 23 percent. In 2017, CMS sent a bulletin to state Medicaid programs informing...

CMS Proposed Rule Aims to Secure 2018 Risk Adjustment Payments

by Thomas Beaton

CMS has proposed a new rule that aims to resolve legal issues over the risk adjustment program’s payment methodology.  The rule would ensure that payers will receive appropriate risk adjustment payments for plan year 2018. The...

Provider Market Concentration Outweighs Payer Concentration

by Thomas Beaton

Healthcare provider systems tend to be bigger, more consolidated, and have more market share than payers in the same metropolitan areas, leaving some payers with less power to negotiate pricing and other contracts, according to the...

CMS Final Rule Extends Short-Term Health Insurance to 3 Year Max

by Thomas Beaton

CMS has issued a final rule that triples the length of time a beneficiary can keep short-term health insurance. The rule allows individuals to purchase a new short-term, limited benefit health plan that lasts for 12 months, or extend...

CMS Approves Wisconsin State Reinsurance Program

by Thomas Beaton

CMS has approved Wisconsin’s plan to launch a state reinsurance program from 2019 to 2023 to help reduce individual state premiums and control the growth of state healthcare spending. The program, called the Wisconsin Healthcare...

12 Attorneys General File Lawsuit Over Association Health Plans

by Thomas Beaton

A dozen state attorneys general are suing the Department of Labor (DOL) over the expansion of association health plan (AHPs).   In the suit, which was filed in the DC District Court of Appeals, the officials argue that broad...

CMS Proposes Site-Neutral Payments, Drug Price Negotiation

by Thomas Beaton

CMS has proposed a rule that would expand the use of site-neutral payments and improve the drug price negotiation process with manufacturers in order to reduce Medicare’s overall spending. The new rule would allow Medicare to...

CMS Proposed Rule Cuts State Authority to Divert Medicaid Payments

by Thomas Beaton

CMS has proposed a new rule that would eliminate a state’s authority to divert Medicaid payments away from providers. The rule is intended to ensure beneficiaries have adequate access to healthcare services through direct...

Transitional Health Insurance Plays Key Role in Coverage

by Thomas Beaton

Transitional health insurance, otherwise known as a short-term health plan, is a temporary insurance policy intended to provide stop-gap coverage when an individual is in between ACA compliant policies.  The National Association of...

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