Insurance

CMS released final rules for both the 2015 Medicare Physician Fee Schedule and the 2015 Hospital Outpatient Prospective Payment System.

bioTheranostics, Inc's Breast Cancer Index, a genomic test quantifying the risk of breast cancer recurrence and predicting which patients will likely benefit from extended endocrine therapy, will be covered by Medicare.

Highmark Inc. won a court ruling Thursday allowing it to exclude UPMC hospitals and doctors from some plans it sells to seniors.

The retrospective study analyzed SEER data from 2001 through 2009, and found that the annual CAD prevalence among Medicare screening mammograms increased from 3.5% to 79.7%.

The retrospective study, results of which were presented at the 2014 Chicago Multidisciplinary Symposium in Thoracic Oncology, showed that the total diagnostic workup cost for the study sample of Medicare beneficiaries was $38.3 million.

An investigation into 2012 Medicare claims for HIV-infected patients unearthed payment for prescriptions that were filled up to 32 days after the patient's passing.

From Medicaid providers that are regulated as insurers alongside managed care organizations, as happens in Mississippi, to "enhanced medical homes," which are found in Colorado, the variety that exists in healthcare delivery across the states has adapted to reflect the shift to accountable care, according to an author writing for the American Journal of Public Health.

In 2015, hospital readmissions will be a growing concern as the maximum penalty increases to 3% of Medicare payments. Researcher from Columbia Business School found that one extra day in the hospital can make all the difference to readmission and mortality rates.

US Health and Human Services Secretary Sylvia M. Burwell announces new progams and financial incentives to help accountable care organizations (ACOs) and professional medical associations make the transition from fee-for-service to value-based healthcare delivery.

Industry experts discussed the big issues facing accountable care organizations (ACO) at the Brookings Institute's event, The State of Accountable Care: Evidence to Date and Next Steps, held Monday in Washington, DC.

Attendees at the ACO and Emerging Healthcare Delivery Coalition meeting held October 16-17, 2014, in Miami, Fla., gained insights to help physicians and accountable care organizations achieve the "Triple Aim" of better population health, greater patient satisfaction, and lower costs. This initiative of The American Journal of Managed Care has now attracted more than 120 members.

Myriad Genetics, Inc., announced today that the Medicare Administrative Contractor (MAC) that has jurisdiction over most molecular diagnostic tests has issued its draft notice on how Medicare will provide reimbursement for Prolaris, a test that Myriad has developed to guide treatment decisions in prostate cancer.

The Centers for Medicare and Medicaid Services wants hospitals to find ways to keep patients from returning to the hospital, and the agency has created rewards and punishments in pursuit of this goal. A study in The American Journal of Managed Care is just one of a pair of recent clinical trials that finds readmissions may be beyond some hospitals' control, and policymakers might need to rethink their approach.

Quality of care varies according to the compensation methods used in primary care, but the relationship between compensation methods and preventable hospital admissions is inconsistent.

Accountable Care Organizations participating in the Medicare Shared Savings Program will have access to a new initiative that will support care coordination across the country, according to CMS. Up to $114 million in upfront investments will be made available.

The quality bonus payments tied to CMS' star ratings makes it critical that health plans receive a 4 or better, Jonathan Harding, MD, chief medical officer of the Senior Products Division at Tufts Health Plan, said at the America's Health Insurance Plan's National Conferences on Medicare and Medicaid, and Dual Eligibles Summit in Washington, DC, from September 28 to October 2.

Ohio is the latest state to experience a rough transition to managed care in its Medicaid program, according to weekend reports. Delayed payments and service disruptions to fragile patients are among the complaints. Kentucky had a similar bumpy start when it changed to Medicaid managed care in 2011, and Kansas has had many problems recently.

For the third year in a row, Medicare Part B monthly premiums and deductibles will remain unchanged at $104.90 and $147, respectively, according to HHS Secretary Sylvia Burwell.

How a health plan performs in the CMS star ratings to going to have a bigger impact on their finances in the coming years, Snezana Mahon, PharmD, senior director of Medicare solutions at Express Scripts, said.