Resources

Developments in Medicare Secondary Payer Law

Two recent legal decisions out of the Eleventh Judicial Circuit in and for Miami Dade County indicate that Medicare Advantage Organizations (MAOs) may be able to obtain reimbursement from no-fault liability carriers pursuant to Medicare Secondary Payer law on a class-wide basis. On April 20, 2017, the Honorable Judge Antonio Arzola entered a 56-page order...
Read More

HHS-Operated Risk Adjustment Data Validation – 2016 Benefit Year Implementation and Enforcement

The Centers for Medicare & Medicaid Services (CMS) released a memo stating that it would not hold plans accountable for not validating high-risk claims from 2016. The Affordable Care Act established a risk-adjustment program which provides financial aid to those insurers that cover individuals with complex health conditions.  The law mandated that auditors and the Department of Heath...
Read More

Justice Department Appeals Moda Health Risk Corridor Decision

The U.S. Justice Department appealed a $214 million decision from February to pay Moda Health over money owed to the risk corridor program. The Affordable Care Act (ACA) created the risk corridor program to pay insurers for losses incurred on ACA exchanges. The Centers for Medicare & Medicaid Services (CMS) hasn’t paid the full amount...
Read More

Anthem Blue Cross Nears 60% Value-Based Care Spend

Anthem reports that 58 percent of its reimbursements are now paid via value-based care models. Of that spend, over 75 percent represents shared savings agreements and shared savings/risk arrangements, according to Anthem CEO. The payer is now working with over 64,000 providers engaged in Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) who are...
Read More

MSP Recovery Makes History Again

After several wins at the U.S. Court of Appeals for the 11th Circuit, MSP Recovery made history again obtaining class certification for Medicare Advantage Organizations based on the principles of Medicare Secondary Payer law, against IDS Insurance Company. On April 20, 2017, the Honorable Judge Antonio Arzola entered a 56-page Order Granting the Motion to...
Read More

Humana To Focus On Medicare Part D and Medicare Advantage

Humana President and CEO Bruce Broussard said in the company’s annual shareholders’ meeting that the company will focus on Medicare Part D and Medicare Advantage patients. The emphasis on the Medicare population comes as more baby boomers become Medicare beneficiaries. Despite a failed merger with Aetna, Humana had a strong fiscal year. A federal court...
Read More

CMS Wants Private Hospital Error Reports To Go Public

The Centers for Medicare & Medicaid Services (CMS) wants to make reports by private healthcare accreditors public according to a proposed rule. Private accreditors, such as the Joint Commission, may spot errors and safety issues at hospitals during inspections, but the public doesn’t know because the information isn’t released. The proposed rule would require accreditors...
Read More

Supreme Court Rules Against Federal Worker In Health Benefits Case

In Coventry Health Care of Mo., Inc. v. Nevils, the Supreme Court in a unanimous decision found that an express preemption clause in the government’s contracts with private insurers under the Federal Employees Health Benefits Act (FEHBA) trumps state laws that prohibit insurers from demanding the beneficiaries reimburse them. The SCOTUS reversed the Missouri Supreme...
Read More

CMS Issues Proposed Rule for 2018 Payment Policy Updates for Medicare Hospital Admissions

Last week the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update 2018 Medicare payment and policies when patients are admitted into hospitals. The new rule, proposes an increase of about 1.6% in operating payment rates for general acute care hospitals paid under the Inpatient Prospective Payment System (IPPS) that participate...
Read More