Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Policy

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...

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...

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...

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...

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...

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...

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...

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...

Senate Hearing Opens Policy Discussion on Prescription Drug Costs

by Thomas Beaton

At a Senate HELP Committee hearing this month, policy experts and advocacy groups suggested several strategies that could lower prescription drug costs, including removing Medicare Part D cost-sharing, increasing federal oversight of the...

Individual Mandate Repeal Would Lead to Payer Financial Losses

by Thomas Beaton

A repeal of the individual mandate, as included in the current GOP Senate tax reform plan, would result in financial losses for payers that could not be offset by cost-sharing reduction payments, the Academy of American Actuaries says....

Prescription Drug Spending Cuts Require Payer Policy Changes

by Thomas Beaton

The US’s current prescription drug policies require updates that cut prescription drug spending while increasing competition in the market, a new report from the National Academies of Sciences, Engineering, and Medicine (NASEM)...

Commercial Payer, Medicare, Medicaid Fraud Cases Top $49.1M

by Thomas Beaton

The Department of Justice (DoJ) recently detailed three cases of healthcare fraud targeting private payers, Medicaid, and Medicare that totaled $49.1 million. The schemes involved common fraud tactics such as illegal kickback operations...

Senate Passes Tax Bill, Individual Mandate Repeal in 51-49 Vote

by Thomas Beaton

The US Senate voted 51-49 to reform national tax policy and simultaneously repeal the Affordable Care Act’s individual mandate, major news outlets reported at the end of last week. GOP senators only lost one Republican vote and were...

CMS Updates Payer Guidelines for 2019 Qualified Health Plans

by Thomas Beaton

CMS has issued a draft letter that outlines guidelines, dates, reporting, and regulatory requirements for payers that want to sell qualified health plans (QHPs) in 2019. The Annual Letter to Insurers includes new information, and updates...

Medicare Advantage Value-Based Insurance Design Updates for 2019

by Thomas Beaton

The Medicare Advantage (MA) Value-Based Insurance Design Model (VBID) for 2019 will extend into fifteen new states, allow Chronic Condition Special Needs plans to participate in the model, and allow all participating plans to specialize...

Medicare Advantage, Part D Updates to Shift Control to Health Plans

by Thomas Beaton

CMS is proposing regulatory changes that would offer health plans additional flexibility to design and implement Medicare Advantage (MA) and Part D Medicare benefits.   The rule would reduce administrative burdens by allowing plans...

ACA Individual Mandate Repeal Could Cut Insured Number By 13M

by Thomas Beaton

As a potential repeal of the ACA’s individual mandate faces the US Senate, the Congressional Budget Office (CBO) and Joint Tax Committee (JTC) found that a repeal would cut the number of insured individuals by four million in...

Top 5 Most Common Healthcare Provider Fraud Activities

by Thomas Beaton

Healthcare provider fraud is extraordinarily common and can be conducted at a shockingly large scale.  The largest healthcare provider fraud takedown in US history was announced just recently, resulting charges against 400 defendants...

Providers Caught in Medicare Fraud Schemes Topping $200M

by Thomas Beaton

Law enforcement officials continue to crack down on Medicare fraud schemes that siphon millions of dollars from the programs, as individuals submit fraudulent claims or overcharge for unnecessary healthcare utilization. Federal law...

Maine Referendum Expands Medicaid Despite Governor Opposition

by Thomas Beaton

The state of Maine has become the first state to expand Medicaid through a ballot vote that overrides Governor Paul R. LePage’s (ME-R) previous decisions to block the expansion, according to national news outlets. On Tuesday, Maine...

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