Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Policy

AMGA: Align Quality, Performance across Medicare Advantage, ACOs

January 18, 2018 - CMS should work to align quality and performance standards across all Medicare programs, including Medicare Advantage (MA) and the Medicare accountable care organization (ACO) initiatives, says AMGA. In a letter issued in response to proposed changes to MA and Medicare Part D, AMGA President and CEO Jerry Penso, MD, MBA, argued that more standardization across multiple programs would help...


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GAO: Medicaid Home, Community Care Create Financial Conflicts

by Thomas Beaton

Home and community-based services (HCBS) programs funded by Medicaid require additional protections from possible financial conflicts of interest, a new GAO report found. Program assessors, including HCBS providers, state and local agencies,...

Provider Health Insurance Fraud Schemes, Settlements Top $310M

by Thomas Beaton

Law enforcement agencies and federal healthcare administrators including HHS, the Office of the Inspector General (OIG), the FBI, and US Attorney's Offices across the country investigated provider healthcare schemes that defrauded Medicare...

KY Gets Approval for 1115 Medicaid Waiver with Work Requirements

by Thomas Beaton

Kentucky is the first state to receive approval for a 1115 Medicaid waiver demonstration that adds work requirements in order for able-bodied adults to be eligible for the public health insurance program. The Kentucky Health program demonstration...

VA Updates Emergency Care Reimbursement, Payment Activities

by Thomas Beaton

The VA has announced that it will expand provider payment eligibility for emergency treatment services and make  administrative and regulatory changes aimed at creating payment process improvements. The January 9th, 2018 rule extends reimbursement...

CMS to Test Medicaid Waiver “Community Engagement” Incentives

by Thomas Beaton

CMS plans to support the addition of “community engagement” incentives to state 1115 Medicaid waivers that contain work eligibility requirements for able-bodied adults, the agency announced in a press release. The new policy guidance...

VA Union: Investigate $90M in Third-Party Contractor Payments

by Thomas Beaton

The American Federation of Government Employees (AFGE) has sent a letter to VA leadership proposing an investigation into $90 million of improper payments made to the third-party contractors of the Veteran’s Choice program. The inquiry...

Expanding Air Ambulance Service May Help Payers Control Costs

by Thomas Beaton

Expanding air ambulance benefits may help payers lower beneficiary premiums and help beneficiaries avoid several thousand dollars in out-of-pocket healthcare spending. An air ambulance costs between $12,000 to $25,000 per flight to account for...

Proposed Rule Details Association Health Plan Expansion Guidelines

by Thomas Beaton

The Department of Labor (DoL) released a proposed rule that allows small businesses and employee groups to purchase association health plans (AHPs) in lieu of employer-sponsored or individual health insurance. The rule follows an executive order...

Healthcare Insurance Market Profits May Hold Steady in 2018

by Thomas Beaton

Certain segments of the healthcare insurance market, including employer-sponsored insurance and Medicare Advantage (MA), will help to stabilize payer profitability in 2018, predicts a report by A.M. Best. The gains from these sectors are expected...

Affordable Care Act Changes May Bring a Rocky 2018 for Payers

by Thomas Beaton

2017 was a turbulent year for the Affordable Care Act.  Legislative battles in Congress, fluctuating support from healthcare stakeholders, and threats of repeal have left many payers facing an uncertain future. Even though Congress has not...

MS Awarded 10-Year Extension of 1115 State Medicaid Waiver

by Thomas Beaton

Mississippi will be the first state to receive a 10-year extension of a 1115 Medicaid waiver, CMS announced.  The waiver originally implemented in 2003, expands eligibility requirements for individuals who can receive family planning benefits....

DoJ Recovered $2.4B from Healthcare Fraud Schemes in 2017

by Thomas Beaton

The Department of Justice (DoJ) recovered $2.4 billion from federal healthcare fraud cases during 2017, the agency announced in a press release. Healthcare-related fraud recoveries accounted for 64 percent of the DoJ’s $3.7 billion total...

MI Requests Renewal of “Healthy Behaviors” 1115 Medicaid Waiver

by Thomas Beaton

Michigan is asking CMS for a renewal of its 1115 Medicaid waiver demonstration that increased the number of insured individuals in the state and led to a reduction in unhealthy behaviors. The demonstration, entitled the “Healthy Michigan...

Medicare Advantage Cost Benchmarks Create Plan Inefficiencies

by Thomas Beaton

New research from the Commonwealth Fund found that the Medicare Advantage (MA) benchmark bidding system, which was intended to reduce plan inefficiencies, has allowed health plans to benefit financially while remaining cost inefficient. Since...

2018 ACA Open Enrollment Totaled 8.82M Beneficiaries in Last Week

by Thomas Beaton

Approximately 8.82 million beneficiaries enrolled in a health plan during the seven week 2018 ACA open enrollment period, which experienced surges in health plan purchasing activity during the final two weeks. The opening week of 2018 open...

Federal Tax Bill, Individual Mandate Repeal Passes House and Senate

by Thomas Beaton

GOP lawmakers in both the House and Senate passed a federal tax bill that includes a repeal of the ACA’s individual mandate to purchase health insurance.  The bill now heads back to the House for a procedural vote and afterwards to...

Consumers Support Laws to Limit Payer Prescription Switching

by Thomas Beaton

The vast majority of patients living with chronic diseases would support legislation to limit a payer’s ability to switch their prescriptions without medical necessity, according to a new series of surveys.   Ninety-four percent of...

AHIP, BCBS: Association Health Plan Expansion Presents Concerns

by Thomas Beaton

An October executive order that expands the availability of short-term association health plans (AHPs) could present significant challenges for state governments and consumers, asserted AHIP, BCBS, and a number of other payer organizations in...

State Medicaid 1115 Waivers Expand Eligibility, Stabilize Premiums

by Thomas Beaton

A number of state governments have submitted Medicaid 1115 waivers to CMS in order to expand Medicaid eligibility requirements, stabilize their in-state premium rates, manage public health issues, and improve behavioral health access. Currently,...

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