Medicare Advantage Congress

Final Announcement: MAC is now part of Health Care – From Policy to Practice

2009-02-06T10:26:00.001-08:00

The MAC blog is now part of Health Care – From Policy to Practice blog. We have more content, news and networking available to share with you on this new blog. Thanks for your continued readership and make sure to subscribe to the new feed.

http://healthcareinsights.blogspot.com/

Happy Holidays from Medicare Advantage Congress

2008-12-24T00:00:00.000-08:00

We're going to be taking some much needed time away from the world of Medicare/Medicaid to enjoy the holiday season with our loved ones.

Our sincerest thanks for your continued readership of the blog and we look forward to your participation, thoughts and ideas moving forward in 2009.

Stay tuned we're getting ready to launch a new blog that looks at the broader issues of Healthcare, update your RSS feed now as we get it ready for our official launch:
http://healthcareinsights.blogspot.com/

We wish to you a joyous holiday season.

Healthcare Insights To Launch in 2009!

2008-12-23T00:00:00.000-08:00

We're getting ready to launch a new blog that looks at the broader issues of Healthcare, providing breaking news, insights and strategies into Health Plan business and operations., update your RSS feed now as we get it ready for our official launch:

http://healthcareinsights.blogspot.com/

Medicare to Docs: Go Electronic in 2012

2008-12-22T00:00:00.000-08:00

Medicare, the federal health insurance program for the elderly and disabled, will offer financial bonuses to doctors who prescribe drugs electronically rather than on paper. Doctors who do not will face penalties from Medicare starting in 2012. From Reuters.

Medicare states that this is to improve efficiency between doctors and pharmacies and to avoid problems with handwriting, patients who lost prescription notes, etc. However, how much is this going to cost doctors--especially those who are serving low income areas or who are in private practice? I understand that Medicare is now offering monetary incentives to doctors who welcome this program but why bribe doctors into doing something that they will already ahave to do in a few years.

Medicare should, if they are mandating that doctors adhere to this new policy, spend money to educate docs and their staff on the new inititative.

Just the Essentials: Deciding on Medicare Coverage Plans

2008-12-19T06:14:00.000-08:00

We stumbed across this very informative piece this morning by Allsup on MarketWatch that details the 10 most important things that indivudals/caretakers must ask themselves when figuring out appropriate Medicare coverage.

The article stresses that knowing one's healthcare needs is the key to understanding what plans are solid for their needs.

We highly recommend that you print out this list, available here.

U.S. Nursing Homes Get "Zagat" Rated by Feds

2008-12-18T09:19:00.000-08:00

For a listing of the ratings by state, please click here.

By offering ratings to each nursing home, it gives a clear rating of the quality of the home. Though a visit is always encouraged, soon people would be able to choose a nursing home much like choosing a place for vacation.

What is particularly interesting about this report is that non-profit oranizations take better care of their clients than for profit organzations. This is probably because non-profits are so tied into keeping their non-profit status that a system of checks and balances in high order.

An analysis of nearly 16,000 nursing homes reveals for-profit homes are more likely to provide inferior care than their non-profit rivals, according to a USA TODAY examination of the federal government's first ratings of the homes' performance.

The new Zagat-like rating system, released today by the Centers for Medicare & Medicaid Services, assigns homes one to five stars for quality, staffing and health inspections, plus an overall score.

What do you think of the rating system? How will it affect U.S. nursing homes?

Texas Medicaid Fraud

2008-12-17T08:51:00.000-08:00

Oops! More kickbacks for health officials have landed Texan health officials in some serious hot water. What is important about this case, as with all fraud cases, is that it affects the individuals who trusted in others to do their job and to do it well. People don't want to be seen as dollar signs, it grows contempt in the consumer which is just bad business.

This case, with phony advocacy groups and false marketing materials is predatorial and wrong and these individuals deserve to be prosecuted by the full extent of the law.

J&J’s Janssen Pharmaceutica funneled kickbacks to Texas health officials, distributed false marketing materials and deployed phony advocacy groups to get its Risperdal antipsychotic prescribed to low-income Texans, the state alleges in a new filing in an ongoing fraud lawsuit filed in 2006, according to The Dallas Morning News

Medicare assures patients about access to oxygen

2008-12-16T06:24:00.000-08:00

From AP:

Medicare officials tried on Monday to quell growing worry by the elderly that they could lose access to lifesaving oxygen supplies with the start of the new year.

With a rise in phony marketing scams, which this blog has covered, many less than reputable companies are preying on the elderly for more money to offset their own losses during this economic climate. We must assure people that Medicare, though wacky and seemingly mismanaged will not keep individuals from life saving access to medical supplies. Any individual representing a company that claims to do so is wrong. Always do background checks on any company or individual who contacts you our someone you know about your personal Medicare status.

For the rest of this article, please click here.

DaVita gets Department of Health subpoena for documents related to Medicare practices

2008-12-15T07:48:00.000-08:00

From CNN/AP

Dialysis services company DaVita Inc. said Monday it is responding to a Department of Health and Human Services subpoena for documents related to Medicare claims for several drugs.

What do you think will come out of this government audit of DaVita? DaVita has willingly given up all of their documentation and files regarding Medicare claims, so perhaps they have nothing to hide. We'll keep you posted on any new developments.

For the rest of this article, please click here.

First Spanish Medicare Educational Video for Seniors Released

2008-12-12T06:41:00.000-08:00

From MarketWatch:

Award-winning journalist Maria Antonieta Collins has partnered with UnitedHealthcare to create the first-ever Spanish-language Medicare educational DVD for seniors and their caregivers.

What do you think of this outreach to the elderly Latin community?

For more information and for the video, please click here.

AP: Medicare insurers' profits exceed expectations

2008-12-11T07:15:00.000-08:00

Health insurance companies that serve the elderly and disabled in Medicare are realizing significantly higher profits than they anticipated, resulting in the companies getting $1.3 billion more than projected, congressional auditors say.

This is likely due to an increase in payments to companies by the elderly, without an increase in services by the organizations. This money is now being seen as a profit that the companies in question must diligently work with the government to make sure that the clients served via Medicare are getting the best care that they deserve. We'll keep you posted on any new developments.

For the rest of this article, please click here.

AP: Retired players to get new Medicare benefit

2008-12-10T09:16:00.000-08:00

The NFL and its union will pay a combined $100 a month toward the Medicare costs of retired players under a new plan announced Tuesday.

Good for them! I love it when organizations take care of their retirees. Let's hope that more visable organzations follow suit!

For a direct link to this article, please click here.

Indiana: Beware of Medicare scams

2008-12-09T07:28:00.000-08:00

Everyone should be on the look out for Medicare fraudsters out to get money from unsuspecting seniors. Medicare does not contact seniors to go over their health care benefits and medicare does not schedule time to visit with seniors in their homes. If you or someone you know has been contact by a source claiming to help out with Medicare, let the authorities know immediately.

For an example, please click here.

New gun for seniors could be subsidized by Medicare

2008-12-08T08:17:00.000-08:00

From The Raw Story:

A New Jersey company says they have gotten federal approval to market a gun to the elderly and hopes to have it subsized by Medicare.Constitution Arms says its Palm Pistol will aid seniors with arthritis who would otherwise have trouble pulling the trigger. The device allows individuals to shoot by squeezing with their thumb.The company's president Matthew Carmel says its "something that they need to assist them in daily living," and has applied to have the gun approved as a Class 1 medical device, the same designation given by Medicare to walkers and wheelchairs.

For the rest of this article, please click here.

Medicare, Social Security Owe Up to $52 Trillion to Current Retirees and Workers

2008-12-05T09:28:00.000-08:00

Press Release:

DALLAS, Dec 03, 2008 /PRNewswire-USNewswire via COMTEX/ --

Debts Up To Three and Half Times Greater Than Entire U.S. Economy
If the federal government stopped the Medicare and Social Security programs tomorrow -- collecting no more payroll taxes and allowing no more accrual of benefits -- it would still owe up to $52 trillion to those who have already earned these benefits, according to a new study by the National Center for Policy Analysis (NCPA).
"The numbers are staggering," said Andrew Rettenmaier, an NCPA senior fellow and coauthor of the study. "No one thinks we are going to end these programs," he said, "but if we account for federal obligations the way private pensions and state and local governments are required to, the federal government owes up to $52 trillion (in current dollars) as of today."

To put the numbers in perspective, the size of the entire U.S. economy is $14 trillion. The newly released study determined that: --

An estimated $9.5 trillion is owed to current retirees -- an amount
equal to almost $250,000 per person 65 years of age and older in 2008.

-- Adding the liability owed to those nearing retirement (55 and older)
more than doubles the accrued debt to $20.6 trillion.

-- Adding the benefits accrued by younger workers brings the total to as
much as $52 trillion. The beneficiaries include all retirees, as well as
anyone in the workforce above 22 years of age.

For the rest of this release, please click here.

Compliance 360 Enhances Solution for Managing Claims Audits and Appeals

2008-12-04T06:44:00.000-08:00

Compliance 360 Claims Auditor(TM) Reduces Audit Cost Liability for a Wide Variety of Claims Audits including those in the CMS Medicare Recovery Audit Contractor (RAC) program

Compliance 360, a leading provider of Software-as-a-Service (SaaS) solutions for enterprise governance, risk and compliance (eGRC) and the most widely used solution in the healthcare industry, today announced the general availability of its claims audit solution that helps organizations manage a wide variety of claims audits and appeals, including those conducted under the CMS Medicare Recovery Audit Contractor (RAC) program.

The Compliance 360 Claims Auditor is designed specifically for industries such as healthcare, insurance, financial services and student lending where the government is taking an increasingly active role in regulatory scrutiny and enforcement. Regulated organizations in these industries are being asked with increasing frequency to open their records and demonstrate that they are in compliance with the regulatory agency's rules and reimbursement policies. The Compliance 360 Claims Auditor allows organizations to maintain one central system of record for all types of claims audits and provides management with a system of alerts, dashboards, and workflow.

For the rest of this article, please click here.

Baltimore Sun Editorial: Medicare Waste

2008-12-03T06:50:00.000-08:00

Baltimore Sun:

Private health insurance plans that serve nearly a fourth of all Medicare beneficiaries, including more than 40,000 in Maryland, were set up under the assumption that the private companies could provide the same services as Medicare at a lower cost. Instead, many have significantly increased costs without improving care, a new analysis of the Medicare Advantage program shows.It's time for the multibillion-dollar waste to end. Congress should act early next year to reduce these payments to private insurance companies to the level of traditional Medicare. That could save $160 billion over the next 10 years, money that would be better spent offsetting the soaring costs of Medicare as a flood of baby boomers join the program. Enrollment in private Medicare fee-for-service plans has exploded to 2.3 million recently from just 26,000 at the end of 2003. That growth has driven up costs because the government pays the private insurers 13 percent on average more than it would spend for the same number of beneficiaries receiving traditional Medicare. In Maryland, the extra money raked in by the insurance companies added an estimated $28.7 million to the cost of Medicare last year - $16 million to private insurers and $12.7 million in increased premiums paid by seniors participating in Medicare Part B, according to the analysis by the USAction Education Fund for Progressive Maryland, a liberal advocacy group here.
In a campaign debate this fall, President-elect Barack Obama described the extra costs as a "giveaway" to private insurers. And former Sen. Tom Daschle of South Dakota, who has been picked by Mr. Obama to become secretary of health and human services, recently warned that such overpayments to insurance companies are threatening Medicare's solvency.

For the rest of this editorial, please click here.

Economy likely to move up Medicare's insolvency

2008-12-02T06:35:00.000-08:00

From WashingtonPost.com:

Federal health officials estimate that the struggling economy will speed up by one to three years the exhaustion of the Medicare trust fund covering hospital and nursing home care.
Trustees for the Social Security and Medicare programs warned last March that the trust fund for Medicare Part A would become insolvent in 2019. But the chief actuary for Medicare said Monday the economy will likely generate less revenue through payroll taxes than the trustees had projected.

Once the trust fund is exhausted, the federal government will continue to pay for hospital care and other services, but it initially would only have enough money coming in to cover 78 percent of estimated costs.

Trustees issue a once-a-year report on the financial conditions for Social Security and Medicare. In the fall, the trustees get an update that tells them what's happening versus what their latest projection indicated. In the latest update, Medicare's top actuary braced the trustees for a deterioration in Medicare's finances.

For the rest of this article, please click here.

NYT: Medicare’s Too Costly Private Plans

2008-12-01T06:59:00.000-08:00

From NYTimes.com:

Private health insurance plans were supposed to bring better care and lower costs to elderly patients covered by Medicare. Instead they have increased the cost and complexity of the program without improving care, according to new analyses published by the respected journal Health Affairs. Congress clearly has more work to do to remove unjustified subsidies that prop up many of the most inefficient private plans.

Back in the 1980s, private plans — known as health maintenance organizations — were seen as a savior for Medicare. They could provide the same or better services as traditional fee-for-service Medicare, but because of managed care they could do it at a lower cost. Over the years Congress brought other, less managed private plans into Medicare, and in 2003 the Republican-dominated Congress substantially increased government payments to private plans.

Medicare currently pays the private plans — now called the Medicare Advantage program — 13 percent more on average than the same services would cost in the traditional fee-for-service program. Some of the added payments are used to provide extra benefits for enrollees, like reduced cost-sharing or reduced premiums for such extra benefits as vision and dental care.
The added value averages more than $1,100 a year per patient. Not surprisingly, that makes them attractive to individuals and employers seeking coverage for retirees. It has fueled an explosive growth in enrollments. Almost a quarter of all Medicare beneficiaries, more than 10 million people, are enrolled in private plans.

For the rest of this post, please click here.

Bayer to Pay $97.5 Million to Settle Kickback Claim

2008-11-26T07:08:00.000-08:00

From Bloomberg.com:

A unit of Bayer AG agreed to pay $97.5 million to settle accusations that it paid kickbacks to diabetic-equipment suppliers, the U.S. Justice Department said.
Bayer Healthcare LLC was accused of giving $2.5 million to Liberty Medical Supply Inc. to persuade Liberty to provide its patients with Bayer diabetic-testing equipment such as testing strips and glucose monitors, the Justice Department said in a statement.
Bayer also was accused of paying $375,000 in kickbacks to 10 other diabetic suppliers and causing them to submit false claims to Medicare, the government said. From 1998 through 2007 the suppliers filed false claims on the sales to get Medicare reimbursements, the statement said.
“Paying health care suppliers to place a particular brand of device with Medicare beneficiaries violates the law and will not be tolerated,” said Gregory G. Katsas, assistant attorney general for the Civil Division.
Bayer spokeswoman Susan Yarin said the payment puts the matter behind the unit, based in Tarrytown, New York.

For more information, please click here.

Update: Medicare Advantage Payments

2008-11-25T12:10:00.000-08:00

This post on GOOZNEWS.com discusses how several reports have recently taken aim at Medicare Advantage. The NY Times states that payments to health insurance organizations on average are 12 percent higher than what the government would spend on beneficiaries in traditional Medicare, and payments to Medicare Advantage plans are 17 percent higher.

How will the new administration deal with Medicare Advantage, since payments are ridiculously higher than traditional Medicare?

Medicare Advantage Paid Too Much

2008-11-24T13:29:00.000-08:00

Fierce Healthcare reports that studies form the Medicare Payment Advisory Commission suggest that private health care plans for Medicare beneficiaries may be a good place to start cutting. The studies also show that private insurance plans are driving up costs because they are paid on average 13 percent more than allocated for traditional Medicare. Do you think private health care plans should be cut?

Miami physicians sentenced for Medicare fraud

2008-11-21T07:27:00.000-08:00

From BizJournals.com:

Two Miami physicians were sentenced to prison on Thursday for their roles in an HIV infusion scheme that defrauded the Medicare program out of $6.8 million.
A Miami federal court judge sentenced Carlos Contreras, 61, to three years and Ramon Pichardo, 58, to four years in prison. They also were ordered to repay $4.2 million in restitution to the Medicare trust fund.
Contreras and Pichardo each pleaded guilty to one count of conspiracy to commit health care fraud. Contreras was owner and a doctor at CNC Medical Corp. in Miami. Pichardo was a doctor there.
Contreras and Pichardo admitted that, between November 2002 and April 2004, they conspired with others to file $6.8 million in false claims to the Medicare program for HIV infusion services that were not provided or medically necessary.

Medicare Part D Drug plans

2008-11-20T12:08:00.000-08:00

At US News, they have the new prices for most popular Medicare Part D stand alone drug plans. Most have increased a significant amount. See the prices here.

Medicare Troubles with Part D

2008-11-19T11:40:00.000-08:00

From USNews.com:

Phillip Moeller writes,

Besides premium increases, many Part D plans have added other fee hikes, reduced covered drugs, and backed off on other protections as well. These changes are extensive and are layered onto a program with mind-numbing variables. The nation is broken up into 34 coverage regions, for example, and most states offer roughly 50 different private insurance plans with huge ranges of coverages and costs.
Whew! Paul Krugman may have won a Nobel Prize for economics, but I bet even he would have a hard time figuring out the best Part D plans for his elderly relatives. This year, more than ever, though, it will pay to look carefully at Part D choices. So, grab another cup of coffee, and bear with me.
The Part D program began with much fanfare and confusion in 2006. Since then, more than 16 million people ages 65 and over have signed up for the stand-alone Part D plans, and they've tended to stick with their original choices despite many plan changes in 2007 and 2008.

For the rest of this article, please click here.

Medicare drug benefits cause confusion

2008-11-18T10:46:00.000-08:00

In a survey released by MedCo Health Solutions today, we find out that of the 1,000 Medicare beneficiaries selected, that 62% do not understand the doughnut hole when it comes to prescription drugs. More alarming is that 28% of those surveyed stated they weren't aware it existed.

For more information, read here.

6 Wks for Seniors to Sign up For Medicare Drug Plan

2008-11-17T07:49:00.000-08:00

From the Chicago Sun Times

Starting today, seniors have six weeks to sign up for another year of Medicare Part D -- the prescription drug benefit -- that goes along with Medicare Part A (hospitalization), Part B (outpatient and doctor costs) and Medigap (the supplement that covers other costs including co-payments and deductibles).

For more information click on the US Government's website.

The Disabled Have a Long Waiting Time Before Qualifying for Medicare

2008-11-13T07:10:00.001-08:00

Stuart recently posted on MS Related News that Congress and the Obama administration should put an end to the 2 year waiting period people deemed as “too sick” have to face before qualifying for Medicare. Medicare covers both disabled and elderly people, but approximately 1.5 million disable people find themselves waiting for a very long time before receiving any benefits from Medicare.

Of the 1.5 million, 40% are uninsured for part of the wait and 25% are uninsured for the full 24 months. There is new legislation proposed by Rep. Gene Green, D-Texas, and Sen. Jeff Bingaman, D-N.M that would eliminate waiting time gradually over 10 years. Will the Obama campaign help get this legislation passed?

New Rules are Imposed on Medicare Advantage Plan Sales

2008-11-11T11:21:00.000-08:00

Yesterday’s article on ModernHealthcare.com discusses that the Centers for Medicare and Medicaid Services have issued compensation requirements for sales agents that sell Medicare Advantage plans and prescription drug plans to Medicare beneficiaries.

Some of the rules include paying compensation to all agents according to fair-market value and adjusted for inflation for similar products in the same geographic area. To make sure that everyone is compliant with the new rules, agents will have to CMS their compensation structures for the previous three years as well as the compensation structure they are implementing for 2009.

Medical News Today: MedPAC Adopts Recommendations To Improve Transparency Of Financial Ties Between Industry, Physicians

2008-11-10T07:05:00.000-08:00

The Medicare Payment Advisory Commission on Thursday adopted five recommendations to Congress that would require disclosure of the health care industry's financial ties to physicians and other health care professionals, CQ HealthBeat reports. MedPAC will present the recommendations to Congress in March. According to the recommendations:

Congress should require all manufacturers, distributors and their subsidiaries to report to HHS financial relationships with physicians, pharmacists, pharmaceutical benefits managers and their employees, as well as with hospitals, medical schools and medical or health organizations;
Congress should direct the HHS secretary to post the information on a public Web site;
All details regarding no-cost drug samples provided to physicians should be posted on the Web site so researchers can study the impact samples have on prescribing decisions;
Congress should require all hospitals and other entities that bill Medicare for services to "annually report the ownership shares of each physician who directly or indirectly owns an interest in the entity (excluding publicly traded corporations)" and post the information on the Web site; and
Lawmakers should require HHS to submit a report on the "types and prevalence of the financial relationships between hospitals and physicians."

MedPAC Chair Glenn Hackbarth said, "This is about transparency. It's not about condemnation" (Reichard, CQ HealthBeat, 11/6).

For more information please visit the original article here.

Private Plans for Medicare that Cover Dental Care

2008-11-07T11:00:00.000-08:00

This post on AMPSYS discusses how Medicare does not cover dental care, but there are ways around this. There are many private plans for Medicare that do offer such coverage for dental expenses. Some of these private plans include the basic Medicare coverage, and also offer savings in eyeglasses, hearing devices, and dental care as well. The post gives an example of how Humana pays for about 25 percent of fillings, 75 percent of the cost of examinations, cleanings and X-rays, and 50 percent of extractions.

Physicians Receive Medicare Incentive for e-Prescribing

2008-11-06T10:07:00.000-08:00

Pizaazz reports in this article that the Centers for Medicare and Medicaid Services have announced an incentive plan for physicians so that providers will receive a 2% bonus on total Medicare charges during 2009 for using qualified e-prescribing system.

According to CMS, providers must use the e-prescribing systems that:
-Communicate electronically with the patient’s pharmacy,
-Remind physicians about cheaper alternatives (if available),
-Provide Medicare formulary information, and
-Alert prescribers about allergies, improper dosing and drug interactions.

Home Health Care Agencies will Receive a Slight Medicare Payment Increase in 2009

2008-11-05T08:17:00.000-08:00

EmaxHealth recently reported that CMS will slightly increase Medicare payments on average to home health agencies in 2009. It will also take steps to remedy cases in which providers bill Medicare unusually large amounts.

Home health agencies on average are expected to receive an increase of 2.9% or an additional $490 million for changes in costs of goods and services. Agencies will have to report quality data on a regular basis to avoid a 2% reduction in payments.

Medicare Co-Pays and Premiums Expected to Rise

2008-11-04T12:01:00.000-08:00

FierceHealthcare reports today that a recent study conducted by Avalere Health LLC found that for the largest 10 drug companies, premiums are expected to rise up an average of 31 percent next year. It is also speculated that this in term might cause insurers to increase drug co-payments 75 percent (about $7) for generic drugs and a 60% increase (about $40) for brand drugs.

A spokesperson from Humana, an insurer, mentions:

“Prices reflect the experience we've seen over the past three years, and our expectations around what will most interest our members and potential members going forward."

Medicare spending falls

2008-10-31T11:25:00.000-07:00

According to this article at USA Today, the cost of drugs for Medicare fell $6 billion this fiscal year. The reasons for the fall are believed to be: more use of generic drugs, two million fewer participants and seniors avoiding falling in the doughnut hole.

Medicare helps Aetna's ailing income

2008-10-30T07:46:00.000-07:00

As reported by the Associated Press, Aetna faced third quarter losses this year. Although they saw their third quarter profits decrease 44% to $277.3 million, they still saw their revenue increase in healthcare premiums which doubled 8% to $5.09 billion. Medicare premiums increased to $1.21 billion and Medicaid raced ahead to $154.3 million, which accounted for an increase of 72%. Membership of Medicaid also increased 1% to 17.7 million members, which balances out the loss of those with a Medicare membership.

What's the future for healthcare?

2008-10-29T09:00:00.000-07:00

One week from today, the American people will know who their leader is for the next four years. The future president has a huge impact on the future of Medicare. So what are their views on what to do? Whoever wins is up for a challenge, as Medicare spending has increased 40% in the past four years, from $309 billion in 2003 up to $431 billion in 2007. Not to mention, Medicare Part A is set to be bankrupt by 2019.

So what do the two presidential candidates have in mind to turn Medicare around? CBS News covers their plans here. John McCain wants to group together payments to providers into one large sum for better quality care than paying companies on a case-by-case treatment and test basis. He also looks to make those who make over $80,000 a year pay a larger percentage of their own prescriptions. For more on his platform, read here.

On the other hand, Barack Obama wants to allow Medicare negotiate with pharma companies to allow bring down prices of care, as the Vetrans Association currently does. For an in-depth look at Obama's Medicare platform, read here.

Thirteen Recommendations for Eliminating Medicare Fraud

2008-10-27T13:42:00.000-07:00

Medicare fraud schemes are very common in this day and age. The American Association for Homecare has announced 13 recommendations in this post that could potentially eliminate most of Medicare fraud that relates to the home medical equipment (HME) sector. This association works alongside with Congress to implement these recommendations to combat Medicare fraud.

Here are the recommendations set forth by the American Association for Homecare:

Mandate Site Inspections for All New Home Medical Equipment Providers
Require Site Inspections for All HME Provider Renewals
Improve Validation of New Homecare Providers
Require Two Additional Random, Unannounced Site Visits for All New Providers
Require a Six-Month Trial Period for New Providers
Establish an Anti-Fraud Office at Medicare
Ensure Proper Federal Funding for Fraud Prevention
Require Post-Payment Audit Reviews for All New Providers
Conduct Real-Time Claims Analysis and a Refocus on Audit Resources
Ensure All Providers Are Qualified to Offer the Services They Bill
Establish Due Process Procedures for Suppliers
Increase Penalties and Fines for Fraud
Establish More Rigorous Quality Standards

Medigap Solutions

2008-10-24T13:23:00.000-07:00

On Monday we discussed in this post the doughnut hole effect that many participants in Medicare are reaching right now. This latest article, also touches on the subject. One of their suggestions for combating this effect would be to put a little money away each month while they are on the plan and paying very little. Many agree that this is a logical solution, however, as one senior, Jim Walder, stated:

“But I didn’t see four dollar gallon gasoline coming. I didn’t see getting laid off to part-time work coming.”

Other solutions further mentioned in the article include patient assistant programs, using generic medications, and contacting Social Security regarding the Medigap policy.

DragNet Technologies Helps Health Care Providers

2008-10-22T13:10:00.000-07:00

For the past 10 years, Medicare and Medicaid physicians have seen their profit margins shrink from 25% to just under 6%. Much of this change has been attributed to increasing complexity in recording and coding systems. Mentioned here, DragNet Technologies has

"announced the availability of their downloadable medical billing code lists directed toward the needs of healthcare providers all across the United States, especially in the Home Health arena." The article further mentions that "DragNet's goal is to arm healthcare providers in our country with the necessary information to get paid - and get paid quickly - for the services they have provided to Medicare and Medicaid patients"

Hopefully this will help Medicare and Medicaid physicians, and create a trickle down effect to help patients. With increased ease, more physicians maybe inclined to participate in these programs.

Cost of Health Care

2008-10-21T12:08:00.000-07:00

In a recent report from the Centers of Medicare & Medicaid Services, they announced that Medicaid spending will grow at a rate of 7.9% over a 10 year period, with the cost estimated at $674 billion in 2017. It was also noted that the growth rate of the economy at 4.8%, and of health expenditures at 6.7% is lower. By 2013 it is expected that this cost will compromise 8.4% of federal budget in comparison to last years cost of 7%. It was noted in this article that

"Health and Human Services Secretary Mike Leavitt said the analysis was a reminder that Medicaid spending is on an unsustainable path that might threaten the health of the nation’s most vulnerable citizens."

Doughnut Hole is Not So Sweet

2008-10-20T12:52:00.000-07:00

As recently reported here, in a study conducted by the Kaiser Family Foundation, 26% of Medicare beneficiaries who filed using the prescription drug benefit "reached the coverage gap in 2007." Of these individuals, 15% were taking medication for chronic diseases, and quite taking meds during the gap. As Carloyn Clancy from Agency for Healthcare Research & Quality, warns:

"High drug costs are a barrier, but this is the first time we're seeing it documented so plainly. This raises concerns about the consequences for people with serious chronic conditions. There is a growing recognition that the doughnut hole is impairing people's access to medications."

As is further mentioned in the article, this will be an issue that the next administration will have to address. As seen in the post from this past Friday, it seems that the candidates are already aware of the problems, and have plans to address this troubling statistic.

New Obama Campaign Warns Seniors About Medicare Reductions

2008-10-17T07:36:00.000-07:00

I came across this post on The Huffington Post in which it discusses Senator’s Obama’s recent ad campaign that show several shots of distressed seniors in order to drive the message that McCain wants to tax health care benefits and cut Medicare.

The campaign puts the figure at $882 million for Medicare alone. The post also mentions that the McCain campaign did not make a statement about which elements of the program would be cut. Watch the video below:

Top Rated Hospitals have 70% fewer deaths

2008-10-16T13:40:00.000-07:00

As this article reports, patients that are treated in top rated hospitals have a 70% higher chance of surviving, than if they were to stay at hospitals with the lowest rankings. According to the study "HealthGrades Hospital Quality in America", 237,420 deaths of Medicare patients could have been avoided. The four most common reasons for death, in over have the patients included: sepsis, pneumonia, heart failure, and respiratory failure. The study was conducted using 41 million Medicare hospitalization records between the years of 2005-2007.

Should Medicare Pay for Hospital-Acquired Infections?

2008-10-15T11:52:00.000-07:00

The Healthcare Economist poses the question “Should Medicare pay for these hospital-induced health care costs?” in this latest post.

The problem if Medicare implements a policy in which they do not pay for nosocomial infections is that doctors would report nearly all infections as community-acquired rather than hospital-acqiured. This in term would adversely affect the reporting of infections.

What are your thoughts? Should Medicare ultimately pay for hospital-acquired infections?

Extra Payments Made to Medicare Advantage Plans Total $8.5 Billion

2008-10-14T07:26:00.000-07:00

The Healthcare Intelligence Network reports that in 2008 extra payments made to Medicare Advantage Plans will total over $8.5 billion. There are payments reductions scheduled for 2010, but if the Medicare Improvements for Patients and Providers Act of 2008 went into effect in 2008, MA plans still would have paid 10.6 percent more than expected fee-for-service costs.

The majority of the extra payments were made because of the Medicare Modernization Act of 2003 which has expanded the role of private plans in Medicare in an effort to reduce the growth of spending in Medicare.

Government encouraging electronic prescriptions

2008-10-09T09:36:00.000-07:00

As reported by The Columbus Dispatch, Medicare will pay health providers who switch to electronic prescriptions. They believe by having doctors switch to this form of prescription, they will eliminate errors in prescriptions caused by illegible handwriting. For those who switch, Medicare will increase payments in 2009 an 2010 by 2%, 1% in 2011 and 2012, and by .5% in 2013.

Dade County of Miami suspends some Medicare payments

2008-10-08T09:08:00.001-07:00

According to the Miami Herald, the government is suspending payments to the top 10 home health care agencies suspected of Medicare fraud. Medicare is taking an offensive position to find fraudulent businesses, targeting suspicious claims, most having to do with treating diabetic patients at home. The suspension may last up to six months, and 6,500 patients will immediately be affected due to the the impact on skilled nursing visits. These patients will be transferred to other agencies. Read more about the investigation here.

Could Medicare bailout be worse than financial bailout?

2008-10-07T10:49:00.000-07:00

William McKenzie at the Dallas Morning News thinks the current financial crisis will be a walk in the park compared to the next looming disaster - the downfall of Medicare. He believes many people are overlooking the oncoming bankruptcy of Medicare. However Michael Leavitt, the Secretary of Human and Health Services, is someone who is currently recognizing the problem.

The system currently faces two problems:

•There will be too few workers to pay for the benefits Medicare has promised today's workers. Right now, there are about four workers for every Medicare beneficiary. In 20 years, that ratio falls to about 2.5.

•Second, benefit costs will explode in inverse proportion to that dwindling work force. Mr. Leavitt projects that Medicare will rise from about 13 percent of federal spending today to about 23 percent in 20 years.

Do you agree or disagree with Mr. McKenzie? Is Medicare going to fall apart? What can be done to prevent this from happening?

Argus Leader encourages Medicare prescription holders to shop around for perscription coverage

2008-10-06T09:41:00.001-07:00

In an article at Argus Leader, officials encourage Medicare users to shop around for prescription drug coverage. They foresee significant increases and changes in what Medicare part D will cover. For most of the popular drug plans, the most popular drugs could increase in price anywhere from 8% to 64%.

Other price increases include:
The monthly premium for the most popular Medicare Part D plan - the AARP Medicare Rx Preferred Plan - will increase 15 percent, from $32 to $37.

The next most popular plans come from Humana. The premium for the standard Humana plan will go up 60 percent, from $25 to $40, while the premium for the enhanced plan will go from $23 to $38.

Additional News for Medicare’s New Hospital Policy

2008-10-03T12:11:00.000-07:00

Yesterday, we posted about Medicare’s implementation of its new policy in which it will not pay hospitals for any costs that are related to patients being injured due to medical errors while they are in a hospital’s care.

According to this article on NEWSInferno.com, Medicare posts a list of mistakes that it will not pay for on its website. Medicare will not pay for mistakes that include when patients

• Receive incompatible blood transfusions
• develop infections after certain surgeries
• must undergo a second operation to retrieve a sponge left behind from a first surgery
• experience serious bedsores, injuries from falls, and urinary tract infections caused by catheters

It is estimated that this policy will affect several hundred thousand hospital stays out of the 125 million people covered annually by Medicare.

Medicare to stop paying 'never' procedures

2008-10-02T07:41:00.000-07:00

In a report today by UPI, they relate the news that Medicare will stop paying for procedures that happen because a patient is injured while undergoing procedures. Private label insurers have already done this, and it is expected to save Medicare $21 million a year.

Managed Care Provider Cigna adds More States to Medicare Advantage

2008-10-01T13:08:00.000-07:00

CnnMoney.com reports that Cigna will add 15 more states to its individual Medicare Advantage plans next year in order to grow its senior business.

Some of the states Cigna will introduce plans to include California, Florida, Illinois, Massachusetts and Ohio. Of the 13 existing states, Cigna also plans to expand the number of counties to which it offers Medicare Advantage plans. Cigna only recently started offering Medicare Advantage coverage last year. It is looking to expand their services by also adding preventive dental care reimbursement to its Advantage plans for next year.

MD Medicare Choice Under Receivership

2008-09-30T12:42:00.001-07:00

MD Medicare choice in Tampa Florida has been placed in receivership by Leon County Circuit Court Judge P. Kevin Davey as reported here. Their Medicare Advantage plan had more than 16,000 members across 23 Florida counties. The company had already been under administrative supervision by the Office of Insurance Regulation, but following the difficulties in the stock market these past couple of weeks, the SEC has frozen the $27 million that MD Medicare Choice had as reserves in the Primary Fund of Reserve Management Corp. The current Medicare Advantage contract will be void as of today midnight, and policy holders will be switched to Humana policies. For more information call 1-800-758-4806 or 1-800-833-3301 if you are a beneficiary, or 1-800-882-3054 for information about receivership. You can also log on to http://www.myfloridacfo.com/Receiver/.

No Congress in Medicare Please

2008-09-29T12:43:00.000-07:00

As this post in a WSJ blog states, the CEO's of Mayo and John Hopkins have given their opinion in an op-ed piece for the Chicago Tribune requesting Congress to but out of Medicare. They would like Congress to have less oversight and control, and instead, want to have a board providing guidance instead. To quote the article:

Decisions about coverage and payments are inappropriately subject to political influences and inefficiencies. Why should Congress spend time debating how much Medicare should pay for the rental of oxygen supplies? A non-political board could better fulfill the role of overseeing Medicare. The board should function like the Federal Reserve—with independent authority, but reporting to Congress.

Medicare fraud case at Cooper University

2008-09-26T12:12:00.001-07:00

The Philadelphia Business Journal reported that Cooper University Hospital will pay $3.85 million plus interest to Medicare to settle allegations that it defrauded Medicare.

Supposedly, the the Cooper University Hospital increased Medicare charges to both in-patients and out-patients in order to receive higher reimbursements. Supplemental reimbursements occur when the bills are higher than normal and technically called outlier payments.

Brand-Name Drugs are Favored by Medicare Beneficiaries

2008-09-25T12:58:00.000-07:00

According to this article in EmaxHealth, brand-name medications account for almost two-thirds of all prescriptions filled by Medicare beneficiaries. Patients are asking for brand-name drugs when the program provides coverage and are asking pharmacists for generic drugs when they have to pay out of pocket.

When patients switch from brand-name to generic drugs, more than likely they’ve reached the coverage gap in which they must cover the full cost of the prescriptions. Woody Eisenberg, Medco Chief Medical Officer mentions that when Medicare beneficiaries become aware of the coverage gap they "become acutely aware of the cost difference between brand-name and generic drugs and most make the switch."

Billions Paid in Medicare Suspect Claims

2008-09-24T08:53:00.000-07:00

The National Center for Policy Analysis reports that billions of taxpayer dollars have gone to waste because Medicare has paid out claims with blank or invalid diagnosis codes over the past decade according to a new Senate report.

Claims for wheelchairs, drugs, and other medical supplies of Medicare patients were reviewed from 2001 to 2006. During these years, they found at least $1 billion of medical equipment which listed diagnosis codes that had little or no connection to the reimbursed medical items. Here are some findings from the report:

Medicare paid millions of dollars to medical suppliers for blood glucose test strips -- used exclusively for diabetics -- based on non-diabetic diagnoses.
Roughly $4.8 billion in payments were made from 1995 to 2006 despite invalid coding or nothing listed at all; about $23 million of that amount was paid after 2003, when federal rules made clear the codes were required.
Based on a sample of 2,000 of those invalid coding claims, investigators found more than 30 percent could not be verified as legitimate and "bore characteristics of fraudulent activity."
Federal regulations require that Centers for Medicare and Medicaid Services (CMS) pay only for items that are deemed "medically necessary," yet, CMS does not examine diagnosis codes to determine whether the equipment is actually necessary before making payment.
Only 3 percent of claims are reviewed after payment is made.

Sources:
http://hsgac.senate.gov/public/
http://townhall.com/news/us/2008/09/24/probe_medicare_paid_billions_in_suspect_claims

Medicare Monthly Premium Costs Remain the Same for Elderly and Disabled in 2009

2008-09-22T11:11:00.000-07:00

AHN reports that Medicare premiums for the disabled and elderly will remain constant at $96.40 next year, according to the U.S. Centers for Medicare & Medicaid Services.

The premium and deductible paid by consumers cover home health facilities, durable medical equipment, and cost of physicians. The Medicare Part B Program will also retain its costs at $135 this year. So far the only costs expected to rise is monthly premium payment for Part A coverage which will rise form $423 to $443 in 2009.

Medicare rates to stay the same for 2009

2008-09-19T12:39:00.000-07:00

According to Elder Law Answer, it was announced recently that Medicare's monthly premium will stay the same for the first time in eight years. The monthly premium will remain the same, totaling $96.40 a month.

This fee covers portions of fees related to physicians services, outpatient hospital services, and other items.

More advertising dollars going to Medicare Advantage

2008-09-18T08:43:00.000-07:00

In a recent study done by the Kaiser Family Foundation, detailed here at the Washington Post, they found that insurers spent three times more money promoting comprehensive Medicare plans rather than stand alone drug plans. The study was conducted between October 1 and December 31, 2007, with an increased effort looking at what's going on with Medicare marketing practices. For the most part, the commercials emphasized the benefits centered around preventative care, vision and hearing benefits.

Restrictions placed on cold calls by insurance agents

2008-09-17T07:44:00.000-07:00

Effective October 1, insurance agents will no longer be able to cold call the elderly and disabled when trying to sell prescription drug plans. According to the AP, this new law will be enforced by an increased amount of surveillance on the agents as well as reviews of media and print ads published by those.

The new restrictions include:

- No unsolicited contacts with beneficiaries, such as visiting their home or calling them. The prospective customer must initiate the contact.

- No selling of other insurance products, such as annuities or life insurance, to beneficiaries.

- No free meals at promotional or sales events.

- New requirements for training or testing of agents.

Penalties for breaking these law could result in up to $25,000 worth of fines.

Medicare Hospice Protection Act

2008-09-16T12:24:00.000-07:00

Representative Maurice Hinchey has introduced a new bill to Congress to block a new bill from the Bush administration. According to The Ithaca Journal, a bill going into affect October 1 will begin reducing Medicare reimbursement rates by $2.2 billion over the next five years. This could result in hospice patients loosing their hospice care across the country, as it could cost certain hospices $50,000 next year across the country, and as much as $150,000 over the next three years. Hinchey is encouraging Congress to swift action due to the tight time frame they’re working with.

Welcome to Doughnut Hole Season

2008-09-15T11:09:00.000-07:00

In a recent article at the Dallas Morning News, they discuss the current stress one in five seniors is now facing until the end of the calendar year. Doughnut Hole Season is the time of year when low co-payments reach their gap in the drug coverage provided by Medicare, and, as a result, they are faced with staggeringly high payments for their medication. In 2007, 3.4 million seniors faced this situation.

Through the current program, seniors are responsible for full costs once all of Medicare’s payments (co-pays and deductibles) have reached $2150. They do not pick up payments again until citizens spending exceed $5726. However, only one in five will reach this amount.

Senate Investigates Medicare Call Centers

2008-09-12T06:15:00.000-07:00

Yesterday's Wall Street Journal reported on Senator Gordon Smith (R-OR) and his investigation into the quality of Medicare's call center brought to Capitol Hill. The call centers, run by Vangent, are under investigation because "In 50 test calls placed last month, wait times ranged from zero to 45 minutes, and six calls were disconnected while on hold. Call centers have provided at least one piece of incorrect information or been unable to provide a response to at least one question in 90% of test calls placed in the past year," reported the WSJ article. Vangent denies the allegations citing their high customer satisfaction percentages.

What do you think of Senator Smith's investigation?

Humana looses some Medicare Enrollees

2008-09-10T12:29:00.000-07:00

As a result of premium bids that are higher than low income, government assigned members of Medicare, Humana expects to loose 10% of them at the beginning of 2009. However, according to the Wall Street Journal, they believe this could be positive for Humana due to the fact that higher prices would increase the bottom line, shares dropped 5% to $41.75 when it was announced that this could lead to a los of 380,000 eligible Medicare members. To ensure drug coverage for these dropped Medicare enrollees, the government will automatically re-enroll them in private drug care provider programs.

Nothing is Free: The Problem with Free Drug Samples

2008-09-10T09:15:00.001-07:00

Many altruistic doctors give patient drug samples to uninsured patients; thereby, helping the patient to receive the proper medication and save the patient money. Doctors may not be aware that they are actually causing the cost of prescriptions to rise for the uninsured by having a plethora of prescriptions at hand in the office.

This problem does not affect Medicaid directly, as its common practice for Medicaid patients to receive generic prescriptions.

David P. Miller, M.D., lead researcher and internal medicine physician at Wake Forest Baptist said, that "One possible explanation, Miller said, is that because Medicaid patients rarely receive samples, doctors' prescribing decisions for these patients were based purely on what drug they thought was best and not on what samples happened to be available in the closet."

For the uninsured or those that receive free samples; they can be doing wonderfully on the prescribed drug given to them in sample form. But what happens when the samples at the doctor's office run out? Filling the prescription at the pharmacy would crash their budget and may cause health problems.

Overall, patients need to speak with their doctor about their financial and insurance situations. Doctors can then prescribe patients with low-cost/generic drugs for treatment; instead of what is readily available in the office supply closet.

How do you feel about free samples at the doctor's office? How do you think this will affect Medicare patients?

Sources:
News-Medical.Net
CNN
US News & World Report

Medicare Made Easy

2008-09-09T13:34:00.000-07:00

In a latest release, Experion Systems has launched a new edition of their PlanPrescriber tool as reported by MarketWatch. Created by Glen Urban, a Professor at MIT, this new tool gives seniors access to “unbiased advice” for determining their Medicare Insurance plan. It is a free online tool designed to save seniors time, and money, and starts by simply entering a zip code. Those without access to Internet, can also call 877-900-4824. As Ross Blair, Experion Systems CEO, stated:

"The rising costs of prescription drugs is a real burden for seniors on a fixed income. PlanPrescriber allows seniors to switch to the optimal plan based on their individual needs. Seniors can typically save 25% to 50% of their annual prescription drug costs by joining the optimal insurance plan."

Marketing Documents for Medicare Prescription Drug Benefits is Confusing

2008-09-08T06:33:00.000-07:00

The Wall Street Journal blog discusses how marketing brochures for Medicare prescription drug plans are doing a bad job of meeting guidelines set forth by the feds in this latest post.

A report published by the inspector general’s office in the Department of Health and Human Services found that 85% of marketing materials did not meet guidelines set out by the Center for Medicare and Medicaid Services. Some problems with the documents are that a lot of marketing documents that are produced in conjunction with an insurer and a pharmacy fail to mention that other pharmacies are available. This is required by law. Another problem is that some documents do not include required information on the subsidy that is available to beneficiaries with low incomes.

CDC and Columbia find no link between autism and MMR vaccine

2008-09-05T09:51:00.001-07:00

According to this post at the Wall Street Journal Health Blog, the Center for Disease Control and Prevention and Columbia University did a study that found that there is no connection between the Measles, Mumps and Rebella vaccine and autism.

The two researchers conducted a study based on:

The measles virus from the vaccine could reproduce in the intestinal tract, leading to inflammation and bowel permeability. That leaky bowel could permit the release of chemicals that would make their way to the nervous system, causing trouble.

When conducting the research, they looked at children with gastrointestinal problems who had autism and children with gastrointestinal problems with no autism. Studies showed there was no difference between the two sets of children.

Satisfied Medicare Providers

2008-09-04T13:36:00.000-07:00

In a survey conducted by CMS this year, which was administered to 35,000 randomly selected individuals and organizations including physicians, hospitals, and skilled nursing home facilities, Medicare health care providers are still satisfied with Medicare fee-for-service contractors. As indicated by this article, this shows that

"Medicare health care providers continue to be satisfied by Medicare fee-for-service contractors showing a relatively smooth transition to the new Medicare Administrative Contractors (MACs)".

This year the aver score was 4.51 based on a scale from 1 to 6, which is very close to last years score of 4.56. How Medicare contractors dealt with “provider inquires” continued to be the leading sign of satisfaction. This is the third year in a row where this has been the case

Medicare and Medicaid Rise to the Top

2008-09-03T12:56:00.000-07:00

The Wall Street Journal blog reports that while the share of Americans that got health insurance through work or bought it on the private market last year declined, the number of Americans insured through Medicaid and Medicare has increased. These are numbers based on the latest report from the US Census Bureau.

This change shows that there is an overall decline in the percentage of Americans who are uninsured, and this goes against recent trends of rising uninsurance rates. See the full report here.

“Billing balance” stirs up controversy

2008-09-02T14:24:00.000-07:00

Business Week recently collaborated with the CBS Evening News educate the nation on the nature of “billing balance.” When an insurance company covers less of the medical payments than doctors want them to, they turn to the customer for the rest of the payment. Since patients think that their unpaid bills will turn their credit bad, many automatically pay the bills. This has resulted in patients paying $1 billion more a year in medical bills than they’re supposed to. The California Association believes that 1.76 million policy holders paid $5.28 million more than they were suppose to, including 56% of those who were billed

Medicare Pays Too Much for New Generics

2008-08-28T08:59:00.001-07:00

According to this article on The Wall Street Journal Blog when the price of generic drugs plunges, Medicare is slow to reflect that price change.

A report published by the Health and Human Services’ inspector general looks at irinotecan, which is a cancer that went generic in February of this year. The average price of the drug factoring in sales of the branded version was $52. During the current quarter, Medicare was paying about $75 for irinotecan, which is still far above the average price.

Read the full report here.