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Patients “managed” out of benefits on Medicare Advantage programs. Administrative overhead for Medicare fee-for-service operations typically runs at approximately 2-3 percent. Overhead for commercial insurance plans has been reported to be 18-20 percent. So, what services are being denied by Medicare Advantage (MA) plans to account for this cost difference?…
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Controversy Swirls: Payers vs Providers EDITOR’S NOTE: Attorney David Glaser reported this story live on Monitor Monday today. That statement may appear to be somewhat controversial, but it shouldn’t be. First, plans are required to provide the patient with benefits that are at least as generous as those required under…
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The Centers for Medicare & Medicaid Services (CMS) wants to modernize the Medicare Advantage and Part D programs, as well as launch an ambitious expansion of telehealth benefits, according to a proposed rule the agency issued last week. Medicare Advantage (MA) and Part D provide seniors with health and prescription…
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MAs are taking advantage of excessive denials to reduce payments to providers. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently found that between 2014 and 2016, a total of 75 percent of all appealed Medicare Advantage (MAs) denials were overturned, equivalent to roughly…
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There is no need to worry about coding for HCCs or risk adjustment, writes the author. Just follow the coding guidelines. Confusion abounds regarding the application of Section IV ICD-10-CM Coding Guidelines. And while hospital outpatient coders may be more programmed to code additional diagnoses, physician pro-fee coders may just…
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Best practices are described for eliminating redundancies and easing workloads during the HEDIS season now underway.  Healthcare Effectiveness Data and Information Set (HEDIS) reviews are conducted by health plans and government payers every year from January to mid-May. With the official 2018 HEDIS review season now in full swing, this…
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The presence of Medicare Advantage plans in the healthcare marketplace continues to grow. Unless you have been living under a rock, you are aware that healthcare has been a topic firmly positioned at front and center in Washington, D.C. for the past nine months. This past week has been highlighted…
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Medicare Advantage (MA) programs continue to gain popularity, with about one-third of Medicare beneficiaries currently enrolled in a variety of MA programs. MA plans are issued by MAOs, or Medicare Advantage Organizations, that are typically insurance companies. Medicare beneficiaries are attracted to these programs because they offer increased coverage for…
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The American College of Physician Advisors (ACPA) has responded to a Centers for Medicare & Medicaid Services (CMS) request for recommendations for improvements to the Medicare Advantage program with a detailed position paper outlining a wide variety of proposed changes. In an April 24 letter to U.S. Secretary of Health…
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The recently filed federal whistleblower lawsuit alleging that tens of billions of dollars in improper payments were made to insurers by Medicare Advantage over the course of several years could be just the tip of the iceberg, according to the attorneys for the plaintiff in the case. The suit was…