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MiraMed’s eAlerts are distributed via email every Wednesday, and contains the latest industry information regarding business process outsourcing solutions, helpful coding news, or any number of relevant topics in the fast-paced, ever-evolving world of healthcare. To subscribe, simply complete the form below. Below the subscription form, you will find the archived eAlerts available.
July 13, 2016
Every year, Medicare Administrative Contractors process an estimated 1.2 billion fee-for-service claims on behalf of the Centers for Medicare & Medicaid Services (CMS) for more than 33.9 million Medicare beneficiaries. When beneficiaries or providers disagree with a coverage or payment decision made by Medicare, they have the right to appeal and the Social Security Act established five levels to the Medicare appeals process:
Read more: Changes Proposed to Medicare Appeals Process
July 6, 2016
The Centers for Medicare and Medicaid Service’s (CMS) Hierarchical Condition Category (HCC) risk adjustment model is used to calculate risk scores, which will adjust capitated payments made for aged and disabled beneficiaries enrolled in Medicare Advantage (MA) and other plans.
Read more: CMS-HCC Risk Adjustment Auditing—A Necessary Evil
June 30, 2016
Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Balanced Budget Act of 1997 (BBA) and implemented by the Centers for Medicare and Medicaid Services (CMS). The RA program allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. RA is used to make payments based on the health status and demographic characteristics of an enrollee. Risk scores measure individual beneficiaries’ relative risk and they are used to adjust payments for each beneficiary’s expected expenditures. By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans.
Read more: Understanding Risk Adjustment and the Hierarchical Condition Categories Methodology
June 22, 2016
Healthcare costs in the United States (U.S.) are rising faster than the rate of inflation. Since 2009, healthcare inflation has outpaced the Consumer Price Index by as much as 3.5 percent in a single year.1 The cost of providing care is skyrocketing. Providers and payers need to look for ways to reduce costs so our healthcare system can continue to provide quality care.
Read more: DOJ and NC Attorney General File Antitrust Suit Challenging Anti-Steering Restrictions
June 15, 2016
The Office of the Inspector General (OIG) has issued a pair of Advisory Opinions that could impact non-profit organizations that want to help patients pay for treatment. In the Opinions, 15-16 and 15-17, the OIG views favorably non-profit organizations seeking to financially assist patients with their out-of-pocket expenses associated with the prescription drugs required to treat certain diseases. At a time when all healthcare arrangements are heavily scrutinized by government regulators, the positions the OIG takes in these Advisory Opinions are consistent with previous positions taken by the OIG on such arrangements, though nonetheless welcomed positions allowing organizations to provide patients with the financial assistance they need.
Read more: OIG Views Favorably Arrangements Aimed at Assisting Patients with Financial Obligations
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