Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Medicare Reimbursement

Amerigroup Creates Risk-Based Partnerships for Medicare Advantage

August 1, 2017 - Amerigroup has announced two risk-based partnerships between health systems in Houston and El Paso that aim to enhance quality of care and increase provider access for Medicare Advantage (MA) beneficiaries. Renaissance Physicians Organization (RPO) in Houston and El Paso Integral Care enter the risk-based agreements on August 1st. Providers will be held accountable for delivering long-term...


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Two Payers Liable for $32.5M in Medicare Advantage Fraud Suit

by Jesse Migneault

Insurers Freedom Health and Optimum Healthcare have agreed to pay $32.5 million to avoid further litigation in a whistleblower lawsuit which alleges systemic Medicare Advantage fraud.    The insurers will pay the federal government $16.7...

CMS: Payers May See 2.95% Rise in Medicare Advantage Revenue

by Thomas Beaton

CMS announced updates to the Medicare Advantage (MA) program and Part D Prescription Drug Program, including an expected 0.45 percent increase in revenues for payers and the potential for up to 2.95 percent in revenue growth. “Medicare...

AHA Questions CMS Medicare Advantage Risk Score Calculation

by Kyle Murphy, PhD

The American Hospital Association (AHA) has voiced concerns about the methodology the Centers for Medicare & Medicaid Services (CMS) intends to use to calculate risk scores for health plans under the Medicare Advantage and Part D prescription...

House Speaker Paul Ryan Proposes a Privatized Medicare System

by Vera Gruessner

House Speaker Paul Ryan announced in an interview with Fox News Channel several days after the presidential election that the Republican-controlled Congress and White House will look to create a privatized Medicare system and cut funding from...

Medicare Diabetes Prevention Program Saves $2,650 per Patient

by Vera Gruessner

In March 2016, the Department of Health & Human Services (HHS) proposed the expansion of Medicare coverage for the Diabetes Prevention Program. The funding for this program comes from the Affordable Care Act and research shows that Medicare...

Medicare Advantage Premiums Drop 13% Due to Affordable Care Act

by Vera Gruessner

The Centers for Medicare & Medicaid Services (CMS) announced in a press release late last week that the average Medicare Advantage monthly premium will be 13 percent lower in 2017 than before the Patient Protection and Affordable Care Act...

CMS Accountable Health Communities Model Stresses Social Needs

by Vera Gruessner

This past January, the Centers for Medicare & Medicaid Services (CMS) announced a new funding opportunity for a program called the Accountable Health Communities (AHC) Model, which focuses solely on the social needs of Medicare and Medicaid...

Rising Specialty Drug Prices Plague CMS, Medicare Beneficiaries

by Vera Gruessner

Even though the Obama administration’s Patient Protection and Affordable Care Act assisted Medicare beneficiaries by attempting to end a drug coverage gap called the “doughnut hole” through plan payments and drug manufacturer...

Could Public Option Strengthen ACA Health Insurance Exchanges?

by Vera Gruessner

The ACA health insurance exchanges are facing greater risk now that a number of healthcare payers have decided to drop out of the marketplace. UnitedHealthcare was the first to announce its departure from the ACA health insurance exchanges. More...

CMS Bundled Payment Models Address Cardiac Care, Hip Surgeries

by Vera Gruessner

The Centers for Medicare & Medicaid Services (CMS) have recently begun implementing additional alternative payment models centered on episodes of care. CMS has proposed new rules for managing the costs of care and coordination among Medicare...

How the MACRA Rule, Baby Boomers Impact Medicare Payment

by Vera Gruessner

Last month, Andrew Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS), spoke at the American Medical Association 2016 Annual Meeting about new strategies to pay for Medicare and unlock opportunities for greater...

Medicare’s Hospital Insurance Trust Fund May Deplete by 2028

by Vera Gruessner

The Medicare program may be in trouble with regard to its financial standing. The latest Medicare Trustees report found that the Hospital Insurance Trust Fund may be depleted in as little as six more years. The longest it is expected to last...

17 Health Payers Participating in CMS Oncology Care Model

by Vera Gruessner

The Centers for Medicare & Medicaid Services (CMS) is implementing a new payment and healthcare delivery system called the Oncology Care Model. This particular reimbursement program will involve multi-payer arrangements in which healthcare...

Humana’s Top Suggestions for Operating Bundled Payment Models

by Vera Gruessner

The major health payer Humana will be moving toward adopting additional bundled payment models that will serve Humana Medicare Advantage members. The payer will be partnering with four orthopedic specialty establishments through these bundled...

4 Steps Toward Reforming the Medicare Program, Lowering Costs

by Vera Gruessner

The Medicare program will need to be reformed in order to account for the rising costs of running this major public health plan.As the baby boomer population gets older and more retired Medicare beneficiaries enter the system, the costs of operating...

Medicare Advantage Plans Decrease Avoidable Hospitalizations

by Vera Gruessner

The Centers for Medicare & Medicaid Services (CMS) may be able to reduce healthcare spending by decreasing the number of hospitalizations, emergency room visits, and other expensive medical care services.  This could be done by bringing...

How the SMART Act Resolved Medicare Secondary Payer Issues

by Vera Gruessner

The Centers for Medicare & Medicaid Services (CMS) has released its final rule detailing a timeline for the expansion of the Medicare Secondary Payer Web portal, which must meet the requirements of the Medicare IVIG Access and Strengthening...

Audits against Medicare Advantage Organizations Found Subpar

by Vera Gruessner

In order to ensure government funding isn’t used to pay erroneous or fraudulent medical claims, the Centers for Medicare & Medicaid Services (CMS) conducts risk adjustment data validation (RADV) audits among Medicare Advantage organizations....

Do Medicare Part B Prescription Drug Changes Hurt Rural Hospitals?

by Vera Gruessner

The proposed changes to the Medicare Part B prescription drug program is finding opposition among multiple medical organizations. The Centers for Medicare & Medicaid Services (CMS) will need to address the problems in the new proposed rule...

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