Anthem Medicare Preferred PPO Plan and Rates

Posted by:  :  Category: Medicare

Anthem Blue Cross Life and Health Insurance Company (Anthem) is the legal entity that has contracted with the Centers for Medicare and Medicaid Services (CMS) to offer the Medicare Advantage Local PPO Plan(s) (MAPD-LPPO) noted.  Anthem is the risk bearing entity licensed under applicable state law to offer the MAPD-LPPO plan(s) noted.  Anthem has retained the services of its related companies and the authorized agents/brokers/producers to provide administrative services and / or to make the MAPD-LPPO plan(s) available in this region.  Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.  Anthem is a registered trademark of Anthem Insurance Companies, Inc.  The Blue Cross name and symbol are registered marks of the Blue Cross Association.
Source: johnconner.com

Video: Differences between Medicare PPO & HMO Plans

Medicare Advantage PPO Plans

These plans may or may not have a plan premium whereas several more of the HMO types hove none other than your normal Part B premium to Medicare. Also there will be both an in network out of pocket and an out of network out of pocket if you choose a provider not in network. The out of network providers must agree to accept the terms and conditions of the plan in order to get covered treatment; generally look for providers that accept Medicare on assignment.
Source: medicareinsurancetexas.com

2013 Medicare Advantage Disenrollment Deadline

Advantage plans generally offer lower co-pay expenses than Original Medicare. As with traditional HMO and PPO plans, they are structured around networks of healthcare providers. Patients that want to see outside specialists are required to pickup the additional costs. Many critics of the program argue that seniors with more serious or chronic illnesses are put in financial jeopardy by the managed care limitations.
Source: medicarewire.com

AARP Medicare Complete « Insurance News from Crowe & Associates

United has an AARP Medicare Complete branded product in most states.  In some states they have multiple plans.  The AARP branded Medicare Complete plans come in three types: HMO, POS and PPO.  The plans all have the same basic copay structure and more or less operate in the same manner with the only real difference being that the POS and PPO plans have out of network coverage.
Source: croweandassociates.com

Newsroom – Blue Cross Blue Shield of Michigan adds University of Michigan Health System to new Medicare Advantage PPO Network

DETROIT – Blue Cross Blue Shield of Michigan has added the University of Michigan Health System to its growing network of Medicare Plus Blue℠ PPO providers. The move gives seniors who purchase the competitively priced plan access to all of the U-M hospitals and approximately 2,200 providers. The inclusion of the U-M Health System in the Blues’ new Medicare Advantage PPO plan represents a key piece in a network that now includes nearly all acute-care hospitals in Michigan. Other recent key additions include Scheurer Hospital in Huron County and all four MidMichigan Health hospitals and ancillary services. "The University of Michigan is one of the premier hospitals and a very important network of providers for us to have in our PPO product," said Julie Maier, manager, Senior Markets. "We’re working hard to make sure that our PPO network is comprehensive so people have broad access to care." The Medicare Plus Blue℠ PPO, announced in October, has lower premiums than Original Medicare plus a Part D prescription drug plan and supplementary coverage while retaining worldwide coverage for emergency care. It also provides services that aren’t available in Original Medicare or Medicare Supplemental plans. The new plan currently has a network of 23,000 physicians and 136 hospitals in 75 of Michigan’s 83 counties. Depending upon region, premiums will cost between $61 and $141 a month, compared to $183 per month for the BCBSM Medicare Supplemental (Medigap) Plan C product combined with a standalone Part D prescription drug benefit from the Blues. Some benefits covered in the PPO product not covered by Original Medicare or Medicare Supplemental are:
Source: bcbsm.com

Uwe E. Reinhardt: Comparing the Quality of Care in Medicare Options

Both traditional Medicare and Medicare Advantage plans are monitored annually through surveys of patients, using the Consumer Assessment of Health Care Providers and Systems, known in the trade as Cahps. The findings from this survey make it possible to compare traditional Medicare with Medicare Advantage plans on quality. As Medpac reports in Table 12-8 of Chapter 12 of the March 2012 report, the commission found little difference in the relatively few quality-performance scores of the traditional Medicare and Medicare Advantage plans.
Source: nytimes.com

Aetna Selected to Provide Medicare Advantage PPO Plans to Retired State Employees in Pennsylvania.

Aetna provides health benefits to more than 1.1 million members in Pennsylvania. About Aetna Aetna is one of the nation’s leading diversified health care benefits companies, serving approximately 36.8 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities and health care management services for Medicaid plans. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, governmental units, government-sponsored plans, labor groups and expatriates. For more information, see www.aetna.com.
Source: blogspot.com

Medicare Advantage: Anthem Preferred PPO

On October 15, 2012, individuals who had the Anthem PPO will be able to select another Medicare Advantage plan for 2013.  On October 1st, you will can begin reviewing and considering the remaining PPOs and HMOs in Las Vegas, NV. Note: There are many changes with Medicare Advantage plans because insurance companies are preparing for increasing costs and lower reimbursement rates from Medicare.  There will be 3 PPOs remaining in Clark County and they will all have a monthly premium.
Source: suncityfinancial.com

California Medicare Insurance: 2013 Anthem Medicare PPO

This plan is also offered in other states but here in California it is now a Local PPO as opposed to a Regional PPO, which means its limited to particular counties The plan used to cover the entire state of California and now only a handful of counties will be able to have access to Medicare Advantage PPO network. In addition. only 3 of the counties will continue to receive the “Zero Cost” option; Los Angeles, San Diego and Ventura. All other counties will now have a monthly premium for this plan ranging from $40-131/mo. For some this is no problem but for many Medicare beneficiaries who are dependent upon Social Security or on a fixed income, this raises huge issues. 
Source: blogspot.com

MCOs use drug plans to attract seniors

While many seniors initially may decide to join a PDP in order to keep their current doctors, MA-PDs will be more cost-effective, noted Bob Atlas of Avalere Health. MA plans are able to spread administrative and marketing costs over a broader revenue base and can manage drug usage better through provider networks. The average MA-PD premium for the coming year is $19 per month, compared with an average of $37 per month for PDPs. Moreover, one-third of MA-PDs are offering zero-premium drug coverage options. In addition, some MA plans are offering extra benefits plus extended drug coverage (usually for generics) for seniors that exceed the basic benefit.
Source: modernmedicine.com

Community Health Plan: Fallon Community Health Plan Ppo

Please note that the termination by Fallon Community Health Plan of the Senior Plan contract with Athol MEDEX, Indemnity, PPO, HMO Blue) BMC HealthNet Plan CBA CeltiCare Health Plan CHAMPVA Cigna Cigna Healthsource Commonwealth Indemnity Comprehensive Benefits (CBC) Fallon Community Health Plan
Source: blogspot.com

Medicare Advantage Plan or Medicare Supplement with Part D Drug Plan

•Each plan has a list (called a “network”) of doctors, specialists, hospitals, and other providers that you may go to• Each plan gives you flexibility to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost more.• You may get care from specialists without a referral or prior authorization from another doctor. If you use plan specialists ,your costs for covered services will usually be lower than if you use non-plan specialists.• Each plan may choose to offer a discount to members if they voluntarily use preauthorization or if they pre-notify the plan when getting out-of-network services.• You get all services covered under Medicare Part A and Part B, although the amount you pay for these services might not be the same as under Original Medicare.• Medicare PPO Plans usually offer extra benefits than Original Medicare but you may have to pay extra for these benefits.• Each plan can charge you a monthly premium amount above and beyond the Medicare Part B premium.• Each plan can charge deductible and coinsurance amounts that are different from those under Original Medicare.• In a Regional PPO Plan, you have an added protection for Medicare Part A and Part B benefits. There is an annual limit on your out-of-pocket costs. This limit varies depending on the plan.• Medicare PPO Plans operate like Health Maintenance Organizations (HMOs) with the following two exceptions:–In HMOs, you generally can only go to doctors, hospitals, and specialists that are part of the plan’s network.–Often, HMOs require referrals and pre authorizations.
Source: indoamerican-news.com

Fair Value Unchanged By WellPoint’s Hiring Of New CEO

Posted by:  :  Category: Medicare

I admit that Swedish stands out as the most inexperienced of these. However, Swedish being CEO could be appropriate for leadership dynamics. Under the CEO, there are four Executive Vice Presidents heading up major business units, including Ken Goulet of commercial and individual business, Richard Zoretic of Medicaid, Leeba Lessin of Medicare, and Lori Beer of specialty businesses. Goulet’s team is responsible for 26 million WellPoint customers, and Zoretic’s for 4.5 million beneficiaries of Medicaid programs. Swedish may need to rely heavily upon Goulet and Zoretic to execute growth strategies for these two largest business units of WellPoint, while he himself would primarily focus on overall cost reduction and up-stream integrations. John Cannon, the interim President and CEO, may also have a strong say in decision-making, as he has demonstrated a decisive and action-oriented leadership style. His leadership has been favored by the market, as the stock appreciated by 9% since 8/28/2012, the day when the previous CEO, Angela Braly, stepped down. In short, I tend to believe that WellPoint’s board already had a strategic plan in mind regarding the company’s future, and they hired Swedish to execute on it.
Source: seekingalpha.com

Video: Angela Braly: How Is WellPoint Innovating to Provide Better Care to Medicare Advantage Members?

WellPoint names hospital executive Swedish new CEO

Swedish, 61, will be charged with guiding the nation’s second-largest health insurer through sweeping changes, as the industry prepares to cover millions of newly insured people who gain coverage under the health care overhaul. Insurers also are adjusting to fees and coverage restrictions imposed by the overhaul and facing growing pressure to keep ever-rising health care costs in check. Some on Wall Street expected the Blue Cross Blue Shield coverage provider to pick someone with more hands-on experience in the complex business.
Source: seattletimes.com

Find Job Openings, Career Employment Opportunities, Post Jobs

With sophisticated technology we are able to present in real-time almost every newly listed job that has just been posted with thousands of sites. We simply aggregate (that is where we derive our name) each new job as it is posted with all the major sites. Now you don

Idaho has advisers on hand as Medicare deadline approaches

Posted by:  :  Category: Medicare

Gang of Six - Cartoon by DonkeyHoteyThe SHIBA program this year launched a mini call center and a marketing campaign. Supervisor Phyllis Barker said SHIBA’s volunteer advisers are getting about 700 calls per week just in the main office in Boise. That doesn’t include three other regional SHIBA offices. There are 150 trained volunteers working as SHIBA counselors around the state.
Source: idahostatesman.com

Video: What Is Idaho Medicaid

Idaho Has Several Parts to its Medicaid Plan Insurance Families.com

The Basic Benchmark plan gives you all that, plus coverage for dental, vision, basic mental health, therapies, prosthetics / orthotics, durable medical equipment and supplies, and school based services. The Enhanced Benchmark plan gives you all of that coverage, plus private duty nursing, ICF/ID, expanded mental health clinic, psychosocial rehabilitation, and more.
Source: families.com

Idaho Governor Will Oppose Medicaid Expansion

As you’ll hear in a moment, we have some pretty good ideas about that kind of managed care model. But there’s a lot more work to do, and we face no immediate federal deadline. We have time to do this right, and there is broad agreement that the existing Medicaid program is broken. So I’m seeking no expansion of those benefits.
Source: firedoglake.com

Physicians Fear Medicare Cuts Due to Fiscal Cliff

(WASHINGTON) — Medicare physicians are preparing for fee hikes for their patients if Congress is unable to resolve the fiscal cliff, according to a statement by the Centers of Medicare and Medicaid Services (CMS). According to the statement, “Medicare Physician Fee Schedule claims for services rendered on or before December 31, 2012, are unaffected by the 2013 payment cut and will be processed and paid under normal procedures and time frames,” but the CMS will notify Medicare physicians “on or before January 11, 2013” if fees will go up. The CMS says, “We continue to urge Congress to take action to ensure these cuts do not take effect.” Copyright 2012 ABC News Radio
Source: eastidahonews.com

Does Medicaid Cover Dental in Idaho?

Adult dental benefits are important to ensure good oral health and also overall health. Medicaid is a primary vehicle for acquiring dental benefits among adults with low incomes. States have the flexibility to decide the dental benefits that needs to be provided to adult Medicaid enrollees. States often choose to offer a more limited set of covered services to adults than to children as the coverage for adult dental service is optional.
Source: medicareidaho.com

Travel for Seniors: Idaho

This post is a guest post by John Walters who is a freelance writer who attended the 1973 Clarion West science fiction writing workshop and is a member of Science Fiction Writers of America.  He writes mainstream fiction, science fiction and fantasy, and memoirs of his wanderings around the world.  For many years he lived in Greece with his Greek wife and five sons and taught English as a second language to help pay the bills, but he has recently moved back to the United States and now lives in San Diego. 
Source: medicareecompare.com

DisAbility Rights Idaho Blog: Idaho Medicaid Managed Care Proposal

The PMPM method does not by itself provide incentives for effective DD supports services or treatment. The goal of these supports is to increase the capacity of the person for self determination, independence and community integration. The success of such services is not measured by their physical health status or need for more expensive medical treatment. Short of institutional placement, there is no consequence to the MCO for providing inadequate or ineffective services and supports. Placement in a state facility like SWITC would even be a net savings to the MCO and for certain individuals ICF/ID placement could be a savings over a robust and effective community supports plan. To be effective, there must be a strong incentive to provide effective developmental services and supports. This can only be accomplished with a robust and accurate quality assurance system and well designed incentives to meet the expectations of that system. We are not aware of any examples of such a system. Traditional health insurance plans do not have expertise or experience with these services.
Source: blogspot.com

Happy 46th Birthday for Medicare, Medicaid and Social Security

Medicare, Medicaid and Social Security are critical programs that help Ida-hoan’s get needed health care and keep countless seniors out of poverty. July 30, 2011 marks the 46th birthday of these programs. Normally we would celebrate with birthday cake and balloons but this year is different. This year, we needn’t be celebrating with elected officials. In Idaho for example, politicians cut $39 million from Medicaid in last year’s legislative session. Now Congress is flirting with the idea of cutting billions from Medicaid, Medicare, and Social Security.
Source: idahocan.org

St. Luke’s Named a Medicare Accountable Care Organization

The group announced today also includes 15 Advance Payment Model ACOs, physician-based or rural providers who would benefit from greater access to capital to invest in staff, electronic health record systems, or other infrastructure required to improve care coordination.  Medicare will recoup advance payments over time through future shared savings. In addition to these ACOs, last year CMS launched the Pioneer ACO program for large provider groups able to take greater financial responsibility for the costs and care of their patients over time. In total, Medicare’s ACO partners will serve more than 4 million beneficiaries nationwide.
Source: stlukesblogs.org

Dentist In Birmingham Al That Take Medicaid

Posted by:  :  Category: Medicare

1pic1thoughtinAug 16 spinach for brains by KatieTTDental clinics and centers in Alabama provide low cost or free dental care to low Birmingham Health Care for the Homeless Coalition On site staff include pharmacists, dentists, doctors, and mental health professionals. The site accepts Medicaid and other government (both federal and state) insurance programs.
Source: localdentist.pro

Video: Medicare Doesn’t Cover Dental Work

Is Dental Insurance Medicare Considered Supplemental?

The cost of a supplemental dental insurance plan will depend on the amount of coverage offered. The basic plans will cost between $25 and $50 a month, for which you would be expected to make monthly or biannual payments. More expensive plans can cost between $50 and $100 a month, but include expensive dental procedures and the largest selection of dentists. Knowing what type of care you require will help finding the insurance to fit your budget.
Source: seniorcorps.org

Filling the gaps in Australia's dental workforce

The Australian Dental Association does not represent the interests of the general Australian society, quite on the contrary, they represent the economic interests of Dentist, and only cares for keeping Dentists wealthy. Why is it OK to have more Doctors to serve the undersupplied sections of our society, but when we are stating having more Dentists, the ADA cries out. Australia needs more Dentists. Dental services need to be an integral part of Medicare. Going to the Dentist should not be a luxury that most Australian cannot afford. And if there are more Dentists, then that is good for the general Australian population, that would mean more competition, and a reduction in absurd high fees from Dentists. Anyway, if Dentists start having some difficulty finding jobs, then they should move out from the leafy well off suburbs from the capital cities, and work at dental practices in smaller cities and towns, which desperately need Dentists.
Source: edu.au

What Medicare doesn’t cover

Medicaid, a government program which provides some health care services to low-income Americans, provides dental care in some cases, but not all. The coverage rules vary, depending on the age of the individual, and the state in which he or she resides. Several proposals to reform the Medicaid policies surrounding dental care have been presented, including a push for more complete coverage. Proper dental equipment can be critically important. Oral pain cause extreme pain and suffering, along with lost productivity and missed days of work. Certain oral problems can also cause complications such as systemic infections which may turn deadly if not treated. In states which provide more extensive dental compressors, the focus is often on routine preventative care, as this saves money in the long term by addressing dental problems early or preventing them from emerging.All individuals under 21 who are on Medicaid have their dental supplies covered. Individuals over 21 can access varying levels of coverage, depending on the policies in their state. Alaska, Arizona, Hawaii, Maine, Michigan, Nevada, New Hampshire, Oklahoma, South Caroline, Tennessee, Virginia, Wisconsin, and Wyoming provide care primarily in emergency situations. Some of these states cover emergency dental surgery, while others only cover basic critical care. Residents of California, Connecticut, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Dakota, Texas, Utah, and Washington can access more extended dental services. Each state on this list has some specific restrictions, such as the number of visits in a year, or a copay requirement, but these states generally offer preventative care, such as regular dental exams and cleanings. Some states exclude emergency care, under the argument that dental emergencies should not occur with routine maintenance. Source: wordpress.com
Source: medicarehelpco.com

Know a good dentist/veneers in the OC, CA area for patients on medicare/medi

Frankly, I can’t understand what the writer is saying in most of the write-up. I assume that the writer fractured his/her incisor(s) in the fall. A veneer would likely be the incorrect treatment for this type of injury, as this is just a cosmetic covering. Veneers and cosmetic services are typically not covered by insurances, especially Medicare or Medicaid. However, CA may be different. The more appropriate treatment would likely be a crown or resin build-up, as these are more often used to fix broken teeth. The crown would be more likely to last over time. The resin build-up would be initially cheaper.
Source: angieslist.com

Calif. Telehealth Project Aims To Boost Dental Care for Thousands

you know, all these articles I read about dental care for children. I never had dental care when I was a kid. I went through all the many teeth that came out when I was a kid in Chicago. The teeth that became my permanent teeth served me until I was 17 when I went in to the air force. All my teeth were fine except a wisdom tooth that was pulled. Now, at 76, 11 years after I retired and no longer have dental insurance., I can’t go to a dentist because I can’t afford it. WHAT ABOUT US! WHAT ABOUT OLDER AMERICANS WHO DON’T HAVE DENTAL INSURANCE. ? We just don’t count. No dentist will help us. There are dentists here in the U.S. that will volunteer to go to other countries to help adults with dental problems but not here in the U.S. WHY???? I live on Social Security and a very small pension. I can barely scrape enough together to pay my bills, GASOLINE(tell the govt to nationalize the oil companies).and my health care. Yes I have MEDICARE, but there is no coverage for DENTAL CARE.
Source: californiahealthline.org

Alaska Medicaid Dental Reimbursement

Alaska Medicaid dental reimbursement is fixed by the Department of Health and Social Services for each dental procedure. There are certain procedures for children that may require prior authorization that the dentist must get before providing the service. The dentist must also seek prior authorization for enhanced dental services for adults. The annual Alaska Medicaid dental reimbursement for adults cannot exceed $1,150. If it exceeds, the additional amount has to be paid by the patient, as long as the dentist informs the patient of the same prior to starting the treatment and the patient consents to making the payment.
Source: medicarealaska.com

Health Products for Members: Health Insurance, Dental Insurance, Fitness

AARP Health is a collection of health related products, services and insurance programs made available by AARP. Neither AARP nor its affiliate is the insurer. AARP contracts with insurers to make coverage available to AARP members.
Source: aarp.org

In Pennsylvania, Medicaid Cuts Reduce Options For Dental Care

Medicaid, a program funded jointly by the federal government and the states, covers the the poor and disabled, and coverage varies by state.  Most states don’t pay for any dental care. Now, in Pennsylvania, Republican Gov. Tom Corbett has reduced Pennsylvania’s 2 million adult Medicaid patients to basic dental care – eliminating root canals, periodontal disease work and limiting the number of dentures a patient can receive. The plan now covers little more than cleanings, fillings — and extractions.
Source: kaiserhealthnews.org

Understanding Paul Ryan’s Medicare reform plan in three minutes

Posted by:  :  Category: Medicare

Deputy Administrator and Director for the Center of Medicare at CMS Jonathan Blum visits Christiana Care to speak about accountable care organizations by Christiana CareThe federal government will determine the minimum level of benefits that all plans must offer. The premium-support payment is capped at the growth of GDP, plus 0.5 percent. The subsidy will be adjusted based on the income level of the consumer.
Source: constitutioncenter.org

Video: What Is Medicare Advantage?

Medicare Targets Health Plans With Low Ratings

Medicare officials are encouraging 525,000 beneficiaries to switch out of these 26 Medicare Advantage and drug plans that have received low ratings for three consecutive years and enroll in better plans for next year. The poor performing plans will have this warning symbol next to their names on Medicare’s plan finder website to steer shoppers to other plans.
Source: kaiserhealthnews.org

Election Over, Obama Announces Medicare Cuts to Fund ObamaCare

During the 2012 election campaign, Democrats denied that ObamaCare made $716 billion in cuts to Medicare in order to provide funding toward $1.9 trillion in new entitlement spending over the next ten years. In an announcement on Friday, however, the Obama administration revealed that it would be significantly reducing funding for Medicare, a move that one health insurance analyst said “would turn almost every plan in the industry unprofitable.” Health insurance stocks tumbled following the announcement that a big chunk of the Medicare cuts would come from the popular Medicare Advantage program, a market-oriented system in which participants can choose coverage by a private company that contracts with Medicare to provide all Part A and Part B benefits. According to health care analyst Carl McDonald, the new rates proposed by the Obama administration will have the net effect of reducing payments to Medicare Advantage plans by seven to eight percent in 2014. McDonald projects: “If implemented, these rates and the program changes CMS [Centers for Medicare and Medicaid Services] is suggesting would be enormously disruptive to Medicare Advantage, likely forcing a number of smaller plans out of the business and creating disarray for many seniors.” According to Richard Foster, former chief actuary to the Medicare program, ObamaCare’s cuts to Medicare Advantage will likely force half of its current participants back into the old Medicare program, originated in 1965. It is estimated that this change will cost Medicare enrollees an average of $3,714 in 2017 alone. Democrats have long been unfriendly toward the Medicare Advantage plan, which was passed as part of the Balanced Budget Amendment of 1997 and has seen tremendous growth over the past 10 years. Today, more than 25 percent of seniors receive their health benefits through Medicare Advantage. Regarding the cuts, America’s Health Insurance Plans’ (AHIP) president Karen Ignagni said, “Washington cannot tax and cut Medicare Advantage this much and not expect seniors to be harmed.” Last year it was revealed that, while AHIP was openly supporting ObamaCare and working on a deal with the White House, it was also secretly funneling over $100 million to the Chamber of Commerce to be spent on advertising designed to convince Americans that the new legislation should be defeated. The administration’s proposal is open to outside comments until March 1st, ahead of the final announcement of the cuts on April 1st. READ FULL SOURCE ARTICLE: 02/20/2013
Source: newmediajournal.us

Health Plans Providing Value to Medicare Advantage Beneficiaries

Health plans are working with seniors and people with disabilities in Medicare Advantage plans to ensure that beneficiaries receive health care services on a timely basis, while also emphasizing prevention and providing access to disease management services for their chronic conditions.  These coordinated care systems provide for the seamless delivery of health care services across the continuum of care. Physician services, hospital care, prescription drugs, and other health care services are integrated and delivered through an organized system whose overriding purpose is to prevent illness, improve health status, and employ best practices to swiftly treat medical conditions as they occur, rather than waiting until they have advanced to a more serious level.
Source: ahipcoverage.com

Report estimates health plan overbilled Medicare $424M

Dec. 17, 2012 – Medicare may have overpaid an estimated $424 million to PacifiCare of California’s Medicare Advantage plan based on risk assessments that in many cases made patients seem sicker than they were, according to a federal oversight agency. Medicare Advantage plans send patient diagnosis codes to Medicare, which boosts plan rates if clients are affected by serious medical conditions. A new report by the U.S. Health and Human Services inspector general says PacifiCare was paid extra for treating patients with cancer or a dangerous bloodstream infection even though medical records didn’t describe those ailments. UnitedHealth Group, which now owns PacifiCare of California, disputed the inspector general’s findings, saying the review of 100 cases could not be generalized to hundreds of other claims. “The audit does not follow Medicare’s own guidelines, standards or accepted methodology for validating risk-adjustment payments,” a statement by UnitedHealthcare Medicare & Retirement says. “In fact, it differs significantly from (Medicare’s) adopted methodology. The OIG appears to have relied instead on a methodology of its own making.” The inspector general’s office reviewed UnitedHealth’s response before issuing the report and maintains that its methods are valid. The report, released Thursday, calls on Medicare to review its findings and discuss them with PacifiCare. A Centers for Medicare & Medicaid Services representative said the agency, which administers the Medicare program, is aware of the report and is willing to work on the matter with PacifiCare. Medicare Advantage plans collect patient diagnoses from doctors and hospitals that are used to assign risk scores to clients. Patients with serious medical conditions entitle the plans to heightened per-patient, per-month Medicare payments. The inspector general reviewed a 2007 contract between Medicare and PacifiCare. Under that contract Medicare paid PacifiCare $2.3 billion to administer care for 188,829 clients. The review examined 100 clients’ risk scores, diagnostic codes and related medical records. The inspector general concluded that 55 risk scores were valid, but 45 were not supported by information in patient charts. The inspector general found that PacifiCare submitted a diagnosis code for a genetic disorder characterized by abnormal brain function in a patient whose records only discussed a fever and a cough. Another patient was reported to have prostate cancer when medical records discussed a shoulder suture removal. For a third patient, PacifiCare submitted a diagnosis code for “unspecified septicemia,” a lethal infection of the bloodstream, when medical records discussed a knee surgery and did not mention a bloodstream infection, the report says. The inspector general directed PacifiCare to repay Medicare $224,388 that was overpaid as a result of the 45 charts with unsupported diagnoses. Applying the estimated overpayment rate to 188,000 PacifiCare patients under the 2007 contract, the inspector general estimated that Medicare overpaid about $424 million. UnitedHealth said in its statement that it has worked with Medicare to improve the accuracy of health plan payments and will continue to do so. “Payment accuracy is in the best interests of UnitedHealth, our health care system partners, and Medicare as we collaborate to provide coverage and care that Medicare beneficiaries need, at a price they can afford,” the statement says. The report comes amid a series of watchdog agency and news reports that examine enhanced Medicare payments that can flow to health providers if they overstate the intensity of patient demands or the severity of their medical conditions. The inspector general found in November that Medicare overpaid nursing homes by about $1.5 billion in 2009 based on claims that patients needed “ultra high” levels of therapy. The report found that claims were “upcoded” because the records showed that the patients either did not need or get the therapy in many cases. The Washington Post also examined “ultra high” therapy use in 2010, focusing on a chain that operates dozens of homes in California. The Center for Public Integrity reported in September that doctors and other medical professionals are steadily billing higher rates for treating Medicare patients, signaling a possible increase in billing abuse. And California Watch reported on high rates of severe medical conditions that entitled Prime Healthcare Services, a growing California-based chain, to bonus payments. Prime Healthcare has said its Medicare billings are legal and based on appropriate patient care. www.CaliforniaWatch.org
Source: yubanet.com

Are you ready for 2013? 4 questions to ask yourself

Don’t forget, if you have Medicare Part B and are in Original Medicare, you’ll have to meet your deductible before your Medicare coverage pays for services and supplies. Next year, the Medicare Part B deductible will be $147. Make sure to plan your health care budget to account for the increased cost of doctor visits for the time that it will take to cover your deductible.
Source: medicare.gov

Turning 65: Finding a Medicare Advantage Plan

This is the fifth in a series of posts that examine the process of signing up for Medicare, navigating its rules, choosing supplemental coverage and planning for health care in a program with a very uncertain future. Here are the first, second and third posts and fourth posts in this series. Ah, those Medicare Advantage (MA) plans!’  The government can’t seem to decide if it loves or hates them.’  On the one hand, when I tried to learn about my options, there was much more MA plan information available from the government than for traditional Medigap policies. ‘ So it seemed like I was being encouraged to select an MA plan. ‘ ‘ ‘ On the other hand, Congress with a big nudge from the president, whacked reimbursements to MA plans, cutting out the overpayments they’d been receiving for years.’  It was costing the government far more to fund the benefits to seniors who picked them than it cost to provide the traditional program.’  Lower payments, experts believe, could cause some MA plans to disappear. While government is betwixt and between on MA plans, I am not.’  I know I would not feel comfortable in a restricted provider network, which is the crux of most of these MA plan arrangements.’ ‘  But I approached the selection process with an open mind, taking a careful look at what’s available and evaluating the advice for selecting one.’  As with Medigap policies and the prescription drug plans that go with them, there were too many choices and too many data points for the average senior to comprehend, let alone make the ‘right’ decision that the marketplace model says will appear, like magic. I understand why seniors fall for misleading or deceptive sales pitches.’  We need a helping hand but all too often whoever is extending it doesn’t have our best interests at heart.’  I had heard lots of these pitches before’the kind where a seller invites seniors to a local restaurant, then glosses over the negatives and highlights insurance deals for a very low or no monthly premium with drug coverage, gym memberships, and vision and dental care thrown in to boot.’  Appealing, no? Now it was time for me to cut through the hype. First, I started my review with the sales brochures I received for MA plans.’ ‘  The giant in this universe, UnitedHealthcare/AARP, sent its brochure in an enticing envelope.’  A big red banner screamed ‘$0 premium Medicare health plans’ ‘enough to make me rip it open.’  The insurer’s Medicare Advantage Guide said that although costs vary by plan, all of United’s MA plans have annual limits on out-of-pocket expenses ‘so you can budget for health care expenses and limit your out-of-pocket costs each year.”  That didn’t mean much since I don’t know what illnesses might befall me.’  Marketing jargon, really, but apparently it works. Another sales piece in the mailing gave concrete info about United-AARP’s MedicareComplete Plan 1 (an HMO) with its out-of-pocket limit of $5,900.’  And the other United-AARP offerings?’  For those I had to turn to the government’s Medicare & You handbook where I ran smack into the bizarre world of MA plans.’  It turned out there were also two PPO plans offered through United-AARP.’  Since PPOs are less restrictive than HMOs, I wouldn’t lose my Medicare benefits by going out of network as I would with an HMO. I learned that there were also three other AARP’  HMO choices’the MedicareComplete Essential HMO with an out-of-pocket limit of $5,900; the MedicareComplete Plan 2 which carried an out-of-pocket limit of $4,200; and the MedicareComplete Mosaic with its limit of $2,900.’ ‘  It’s not uncommon for one insurance company to offer several different Medicare plans with fanciful names, which further confuses consumers. All had no monthly premiums, but they paid different amounts for what’s called durable medical equipment, like oxygen, and for critical treatments like chemotherapy drugs.’ ‘  I also discovered that the United-AARP MedicareComplete Essential HMO did not cover drugs, which would force me into shopping for a drug plan, another headache I didn’t need. The United-AARP MedicareComplete Mosaic seemed ideal with its low out-of-pocket maximum, low copayments for doctor visits, and low coinsurance for the expensive stuff like chemo drugs and medical equipment.’  But based on the sales brochure they mailed to me, which were all about Plan 1, it was not the plan United-AARP was encouraging me to buy.’ ‘  With Plan 1, I would be on the hook for more out-of-pocket expenses’meaning that the carrier would pay less and profit more.’  No wonder they were pushing it.’  A second United-AARP mailing also pushed Plan 1. However, both brochures did disclose a significant variable to look at when choosing an MA plan’the copayments for inpatient hospital stays.’  I knew these copays are often hidden in the fine print, and consumers frequently don’t learn of them until they land in the hospital.’  They are clearly a negative for MA plans.’  FYI:’  Medigap policies pay the copayments for hospital stays, which give them an edge in this department.’ ‘  The copay for Plan 1 was fairly hefty’$175 each day up to $1,400 per stay.’  These could add up for a sick person who had multiple admissions. Emblem Health also sent some Medicare insurance mailers, mostly trying to get me to access their website with my own personal password, which was good for a limited time only.’  They were looking for sales prospects, and I didn’t want to become one, especially since I wasn’t interested in watching some NBA hall of famer on a how-to video telling me how easy it is to choose Emblem’s Medicare options.’  But acting like an average senior who had heard of Emblem Health might, I thought I better take a look at the Emblem plans for New York City. It turns out Emblem offers three HMOs and four PPOs.’  The penalty for being able to go out of network in a PPO is steep. They came with high out-of-pocket maximums’$2,500 for going out of network and $6,700 for staying in network, or a’  $10,000 combined maximum.’  Even though two had no monthly premiums, and two had premiums of less than $100, I didn’t go further with Emblem. While sales people push MA plans with low or no monthly premiums, the premium is not the only thing to consider.’  It’s the mix of policy elements that ultimately determine whether a plan is a good or bad deal.’  And then of course, there’s the unknown of your future health status to consider.’  You need to know how the combination of premiums, in- and out-of-network hospital copays, out-of-pocket limits, drug copays, coinsurance for chemotherapy drugs, and copays for doctor visits interact to determine what a plan will really cost.’  The trade-off for a no-premium plan may be hidden’and high’hospital copays, very high out-of-pocket limits, or the obligation to pay 20 percent of chemotherapy bills.’  It boils down to a game of ‘name your poison.’ I also looked for MA plan information on the Medicare.gov website but did not find it helpful.’  Both the handbook and website gave star ratings for MA plans but they seemed to measure different things, further confusing shoppers who might want to use them.’  The government handbook gave the United-AARP CompleteMosaic plan one star for Member Satisfaction.’  That might be important to know.’  At the same time the government website gave the same plan an overall rating of three stars.’  This certainly raised some questions for me about the usefulness of these stars as a shopping tool. Having done lots of homework, it was time to select a plan to cover Medicare’s gaps.’  Was I going to try one of those Medicare Advantage PPO plans that seemed to offer flexibility and let me keep the doctors that I like?
Source: cfah.org

Arkansas Medicare health plan benefits

Medicare health plan provides coverage for medical needs of people who do not have enough coverage or require additional coverage for specific medical needs. It is a plan offered by the private insurance companies that contracts with Medicare to provide the coverage to eligible individuals. The insurer has significant savings on medical expenses when opting for the Medicare health plan. This plan provides all the benefits that are available with the Medicare Plan provided by the Federal State in Part A and Part B of the plan.
Source: medicarearkansas.com

Uwe E. Reinhardt: The Complexities of Comparing Medicare Choices

Each private plan would have had to offer a benefit package that covered at least the actuarial equivalent of the benefit package provided by the traditional fee-for-service Medicare. Medicare’s contribution (or “premium support”) to the full premium for any of these choices, including traditional Medicare, would have been equal to the “second-least-expensive approved plan or fee-for-service Medicare” in the beneficiary’s county, whichever was least expensive. That premium support payment would have been adjusted upward for the poor and the sick and downward for the wealthy.
Source: nytimes.com

16 Recent Medicare, Medicaid Issues

Here are 16 issues dealing with Medicare or Medicaid that occurred in the past week, starting with the most recent. 1. Last month, CMS unveiled the Bundled Payments for Care Improvement initiative, which is considered to be a bellwether on how bundled payments will work in the future. Because the program has such a large scope, hospital executives — regardless of whether their organization is participating in BPCI or not — need to familiarize themselves with the program, theories and pitfalls. 2. Republican senators reintroduced a bill to repeal Medicare’s Independent Payment Advisory Board. 3. For the 11th straight year, Rep. John Conyers Jr. (D-Mich.) proposed the Expanded and Improved Medicare for All Act, legislation that would establish a universal, single-payor healthcare program akin to Canada’s and other developed countries’ healthcare systems. 4. Wisconsin Gov. Scott Walker (R) refused the federal government’s offer to cover an expansion of the state’s Medicaid program if it met full criteria, but he said he would begin to include the poorest childless adults on the state-federal health plan. 5. A recent study found by expanding its Medicaid program with federal funding, Colorado could save $133.8 million by 2025. 6. House Energy and Commerce Committee Chairman Rep. Fred Upton (R-Mich.) and other representatives of his party released a framework of their plan to permanently replace the sustainable growth rate that would make drastic cuts to Medicare payments to physicians. 7. University of Maryland St. Joseph Medical Center in Towson failed a Medicare inspection after the University of Maryland Medical System acquired it late last year, and the hospital is likely losing millions in Medicare payments as a result. 8. Medicare dominated healthcare components of President Barack Obama’s State of the Union address and was one of the largest targets in the Republican response delivered by Sen. Marco Rubio of Florida. 9. Georgia Gov. Nathan Deal (R) signed the hospital provider fee bill into law, injecting millions of dollars in extra Medicaid reimbursement to the state’s distressed hospitals. 10. HHS and the Department of Justice announced the federal government recovered $7.90 for every dollar spent on Medicare and Medicaid fraud investigations over the past three years. 11. North Carolina Gov. Pat McCrory issued a statement, claiming a review of the state’s readiness to implement parts of the health law indicated North Carolina was not prepared to take on the financial risk of an expanded Medicaid program, nor was it prepared to build and run its own health insurance exchange. 12. A Robert Wood Johnson Foundation report found Medicare readmission rates in hospitals across the U.S. have not changed significantly from 2008 to 2010. 13. An audit found that Arkansas’ Medicaid program erroneously distributed $1.36 million in payments to ineligible recipients since 2009. 14. CMS clarified that critical access hospitals will not need to apply for special exemption when providing outpatient therapy treatments to Medicare patients who have exceeded their annual payment cap for such services. 15. New Mexico’s Human Services Department announced four health insurers will be the primary managed care organizations for New Mexico’s revamped Medicaid program. 16. U.S. District Judge David Campbell in Phoenix ordered that HHS re-review a waiver application for Arizona’s Medicaid copay demonstration project within 60 days, claiming the department’s original approval did not offer adequate explanation.
Source: beckershospitalreview.com

A Call for Mandatory Disclosure of Corporate Political Spending

Second, over the years, this issue has been caught, legislatively speaking, in a weird deadlock between Democrats and Republicans that involves, oddly enough, corporate philanthropic grantmaking. As readers know, corporate grantmaking through 501(c)(3) corporate foundations that file 990s gets disclosed, but direct grants from companies’ executive offices, marketing and PR arms, community relations divisions, etc. can be, and frequently are, done without disclosure. For some years, a Republican member of Congress would introduce a bill calling on disclosure of corporate charitable giving. Democrats (and leading nonprofit associations) have consistently opposed corporate charitable disclosure, saying that disclosure would make corporations apprehensive about supporting some causes and charities. Democrats would instead counter that if Republicans wanted disclosure of corporate philanthropic spending, they should be willing to require the disclosure of corporate political spending. And that’s where the debate would always grind to a halt.
Source: nonprofitquarterly.org

HCC University: New Medicare Web Based Training (WBT) Modules

SCAN is committed to partnering with our physician providers in offering high quality geriatric care to our members. A significant part of that effort is to assist our providers in the provision of accurate coding that will contribute to the quality of care and support the expected revenue from the Medicare program. To this end, we present the following tools and education for all the physicians and groups providing care to our members.
Source: scanhealthplan.com

Appealing Medicare Denials of New Medical Technologies

Posted by:  :  Category: Medicare

20090418jb_EFCAcanvassingPA_30 by SEIU InternationalIn addition to filing reconsideration requests and supporting beneficiary challenges, Providers may appeal individual denied Medicare claims that are denied through the five-step Medicare appeal process (redetermination, reconsideration, ALJ, Medicare Appeals Council).  Providers or patients may also appeal denied claims through their insurer’s appeal process.  However, less than 10% of claims denied by commercial payers and less than 2% of claims denied by Medicare are appealed.  Every payer anticipates that most denied claims will not be appealed.  Nonetheless, reported statistics show that most parties that appeal denied claims up to the administrative law judge level are successful.  Thus, it behooves a provider or beneficiary to appeal the denied claim at least through the ALJ level.  Such claims are favorably reviewed even in the face of a non-coverage LCD because ALJ’s are not bound by a contractor’s LCD, although they must give deference to it.  This is particularly true when the LCD does not appear to reflect the literature or the consensus of medical opinion.
Source: wphealthcarenews.com

Video: State Takeover of Harrisburg, Medicare/Medicaid Funding [Pennsylvania Newsmakers]

Daily Kos: Pennsylvania’s Gov. Corbett refuses Medicaid expansion

After the announcement Monday by Ohio Gov. John Kasich that he would accept Medicaid expansion funds under Obamacare, Pennsylvanians might have hoped that the sanity was spreading, and that their Republican governor too would see the light. No such luck. Pennsylvania Gov. Tom Corbett (R) announced Tuesday that his state will turn down the Medicaid expansion, becoming the first governor of a blue state to officially say no to the coverage provision of the Affordable Care Act that the Supreme Court made optional. “At this time, without serious reforms, it would be financially unsustainable for Pennsylvania taxpayers, and I cannot recommend a dramatic Medicaid expansion,” Corbett wrote in a letter to U.S. Health and Human Services Secretary Kathleen Sebelius. The Medicaid expansion would have provided coverage to 542,000 additional people in the state over the next decade, according to analysis from the Kaiser Family Foundation. That would have cost the state  $2.8 billion over a decade, with the federal government kicking in $37.8 billion to the state. More than 1.3 million Pennsylvanians are uninsured, nearly 13 percent of the state’s non-elderly population.
Source: dailykos.com

ITEM Coalition Issues Survey RE Medicare Beneficiaries and Access to Assistive Technology Devices; Please Complete.

ITEM is currently surveying people with disabilities and chronic conditions to find out if they are experiencing problems accessing the devices needed to function independently.  ITEM is interested in medical device and assistive technology users that live in areas where Medicare has implemented a selective provider contracting program known as the DME Competitive Bidding Program.
Source: drnpa.org

Medicare Takes Center Stage In Close Pennsylvania Races

The campaign jockeying over Medicare comes at a time when the program represents a huge fiscal challenge to both parties. With almost 50 million beneficiaries — and growing at the rate of 10,000 baby boomers every day — the entitlement program is one of the fastest-growing portions of the federal budget. Both parties acknowledge the need to curb its growth; both have also used the issue for political gain, casting themselves as the program’s protectors against what they portray as rivals’ threats.
Source: kaiserhealthnews.org

Ryan Takes to Pennsylvania to Push Medicare Message

Mr. Ryan was extrapolating from a 2010 report from Medicare’s Office of the Actuary. It analyzed the potential impact of lower premium supports paid to private companies that issue Medicare Advantage plans, popular alternatives to traditional Medicare with extra benefits such as gym memberships. To slow the growth of Medicare spending, the Affordable Care Act reduces support for the private plans, which Democrats consider inefficient. Beneficiaries would still be covered under traditional Medicare.
Source: nytimes.com

Democrats Heart Medicare Fraudsters

1. Bookmark us now! Enter Ctrl D to save our URL to your bookmarks 2. Don’t miss an article! Use the RSS feed above or the Email below to stay informed! 3.We look Best with a minimum Screen resolution of 1024×768 and Firefox Browser. It’s Free and Safer than Internet Explorer! Upgrade Now! 4.Below are our Archives and other News and Blog Feeds for your viewing pleasure. Also our Blog Rolls, etc., of other worthwhile contributors to Fair and Balanced News and Commentaries that you won’t find in the Leftist Media that dominates the TV, Radio and Newspapers. Stay Honestly Informed!
Source: wordpress.com

Will Your Estate or Trust Administration be Affected by the New Medicare Surtax in 2013?

Thank you for visiting our blog, make sure to add our rss feed (located below) to your favorite news reader. If you have a question about this area of the law, please drop us an email, we might even post your answer on this blog.
Source: utbf.com

Medicare Key Issue in Close Pennsylvania Races

In the week since Romney’s announcement, Medicare has been catapulted from an issue that political strategists said could make a difference in close races to a central component of congressional campaigns nationwide — especially in states like Pennsylvania, Florida, Minnesota and Ohio with large numbers of older voters.
Source: aarp.org

Pennsylvania Federal Judge Declines To Dismiss Medicare Fraudulent Claims Case

PHILADELPHIA – A Pennsylvania federal judge on Dec. 20 denied the defendants’ motion to dismiss a Medicare false and/or fraudulent records case (United States of America, ex rel. Anthony R. Spay v. CVS Caremark Corp., et al., No. 09-4672, E.D. Pa.; 2012 U.S. Dist. LEXIS 180602).Full story on lexis.com
Source: lexisnexis.com

Pa. Home Health Care Providers Worried About Medicare Cuts

AAHomecare AARP Alliance for Home Health Quality and Innovation Almost Family Amedisys Amedisys Inc. American Association for Homecare American Association for Long Term Care Insurance Apria Healthcare Group Brookdale Senior Living Care.com Center for Medicare Advocacy Centers for Medicar & Medicaid Services Centers for Medicare & Medicaid Services CMS Ensign Group featured First Care Home Health Care Gentiva Health Services Gentiva Health Services Inc. HHS Home Health Depot Home Health International Houston Compassionate Care Humana IntegraCare Intel-GE Care Innovations Jordan Health Services Kindred Healthcare LHC Group Inc MedPAC NAHC National Association for Home Care & Hospice National Hospice and Palliative Care Organization New York Times Paraprofessional Healthcare Institute Partnership for Quality Home Healthcare PHI Scripps Health Sentara Healthcare The Ensign Group Univita VA Veterans Health Administration Visiting Nurse Association
Source: homehealthcarenews.com

Jon Stewart Paraphrases Marco Rubio: ‘Medicare Helps MY Mom, But F _ _ k You’

We encourage users to engage in a respectful discussion of this post, below. Comments are not necessarily representative of MoveOn.org’s views or beliefs, nor are commenters necessarily MoveOn members. This is a community-moderated forum: If you see something offensive, please flag it. If a comment receives enough flags, it will be removed.
Source: moveon.org

OIG: Medicare exposed to financial losses from ID theft

Posted by:  :  Category: Medicare

The report “CMS Response to Breaches and Medical Identity Theft,” issued by the Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) on October 10, investigated CMS’ response to 14 security breaches occurring between September 23, 2009 and December 31, 2011. The medical identities of nearly 14,000 Medicare beneficiaries were stolen during this two-year period— significant when considering CMS’ responsibility to maintain the protected health information of millions of Medicare beneficiaries and their role in developing breach prevention regulations.
Source: ahima.org

Video: Rep. Marchant speech on Medicare ID Theft Prevention Act

Medicare cards should not expose Social Security numbers

“Making the necessary changes will require significant monetary investments, multiple systems and operational changes, not just for CMS and its contractors, but also for (the Social Security Administration), state Medicaid programs, private health plans and providers that CMS interacts with regarding beneficiary information for enrollment and claims payment,” Tavenner said.
Source: triblive.com

Congressional Committee Calls on Feds to Curb Medicare PHI Breaches, Identity Theft

Health Subcommittee Chairman Wally Herger (R-CA) said, “This report adds to the growing chorus of voices that have highlighted the need to protect beneficiary SSNs.  While CMS agreed with the OIG recommendation that it issue a new identification number when a beneficiary’s has been compromised, actions speak louder than words.  Though years of CMS indifference and delay make me skeptical, my hope is that this report finally persuades the agency to stop use of the SSN as the Medicare identification number.”
Source: healthcare-informatics.com

Prevent These High Volume Claim Denials

A medical billing software with the ability to indicate payers requiring authorization as well as track a multiple service/visit authorization as it is assigned to the performed procedures is crucial in assisting office staff with this issue.  Iridium Suite provides a specific area in the patient insurance information section to indicate authorization requirements and to record the authorization details.  Before a claim can be submitted, it is scrubbed for authorization requirements and will warn the user if the authorization is missing.  You are unable to submit the claim without the appropriate authorization.
Source: wordpress.com

Statement to the Record on the Medicare Identity Theft Prevention Act

Under current law, Social Security numbers are used as the main component of a Medicare beneficiary’s health insurance claim number and are displayed on over 50 million Medicare ID cards.  This simply doesn’t make sense.  It puts each of these 50 million people at heightened risk for identity theft and fraud.  We’ve already seen high rates for this type of crime: in 2010 alone over 8.6 million households were victims of ID theft, including one million seniors.  Seniors’ social security numbers are especially valuable because they can be used by thieves to obtain employment, benefits, and credit.
Source: house.gov

Last Year Physician Resident Checklist

The UPIN is assigned by CMS (Centers for Medicare and Medicaid Services).It is a six-character alphanumeric code identifying you as a Medicare provider.Each individual practitioner receives one UPIN, regardless of the number of practice settings he or she works in. You will keep this UPIN throughout your Medicare affiliation, regardless of the state or states you practice in. CMS uses the UPIN to identify the ordering and referring physician, to aggregate payment and utilization information for individual practitioners, to ensure compliance with contractor recommendations for sanctions, and to validate duplicate services.
Source: ctcbom.org

Doctors seek cure to Medicare reimbursement woes

Apparently, two bureaucratic strategies (or perhaps we should just call them snafus) were implemented nearly simultaneously, resulting in the current state of affairs. The first holdup started with a new identification number issued to providers in an attempt to reduce fraudulent Medicare reimbursement claims — a solid idea for a system with a long history of wrongful claims. Along with the new identification number, doctors had to submit paperwork on their individual practices that included updates on things like addresses, new doctors joining the practice and more. The updated information was due by May of last year. But many doctors did not receive their numbers and could not submit their forms. No number, no forms, no money. Simple enough.
Source: ohmygov.com

Dog bites law: Vets howl about WI drug tracking bill

Eighteen other states require veterinarians to report at least some of the data requirements under the PDMP as of July 2012. South Carolina, Kentucky and Arizona have indicated they may move to exempt vets in the future, according to a study by the Minnesota Board of Pharmacy. The study also found most states were unable to point to a case of diversion of controlled substances the National Alliance for Model State Drug Laws is worried about.
Source: watchdog.org

Community Health Plan: Fallon Community Health Plan Federal Identification Number

Identification of potential issues within the community and reporting to appropriate Perform outreach with community leaders on available Federal disaster assistance." President Bush declared a major disaster for Louisiana He later declared a Public Health Emergency for the Gulf
Source: blogspot.com

Medicare Cards Pose a High Risk for Identity Theft Scams

However, the Social Security Administration (SSA) recently made a request for the Centers for Medicare and Medicaid Services (CMS) to take immediate action to issue new cards to beneficiaries. These new cards would not have the individual’s Social Security number printed on them. (See: References 2) This is according to a report by the New York Times. (See: References 2) It was also noted that most private insurance agencies have stopped printing Social Security numbers on their beneficiary identification cards. This is due to the fact that many states have forbidden the inclusion of such personal data, according to the Times. But the SSA doesn’t have the authority to prohibit CMS from placing Social Security numbers on beneficiary Medicare cards. However, Congress does have that authority, according to the N.Y. Times.
Source: bestidentityprotection.net

Silver Cross Physicians Join New Blue Medicare Advantage (HMO) Plan

Posted by:  :  Category: Medicare

Learn how to protect yourself from some of the expenses Medicare doesn’t cover. Attend a free Our All-in-One Package: Medicare Advantage Prescription Drug (MAPD) program in the Silver Cross Hospital Conference Center, Pavilion A, 1890 Silver Cross Blvd., New Lenox.  One-hour sessions will be held on Oct. 26 and Nov. 1, 16 and 28 at 10 a.m. and 1 p.m.  Each seminar features an informative presentation followed by a question and answer session with a BCBSIL Product Specialist.  A sales person will present information and applications. Free valet parking and shuttle service will be available.  Refreshments will be served.  Register to attend by calling BCBSIL at 1-877-632-5920, TTY/TDD 711, 8 a.m. – 8 p.m., local time, 7 days a week.  For accommodation of persons with special needs at a sales meeting, call 1-877-632-5920, TTY/TDD 711. Friends and family members welcome.
Source: patch.com

Video: Blue Medicare Options Illinois or Medicare Options Illinois

Blue cross medicare rx prior authorization

     Find out which medications on IBC’s formulary will require prior authorization. Your doctor will have to get approval in advance from Independence Blue Cross Learn more about Prior authorization – MedicareBlue Rx at yourmedicaresolutions.com 2012 Prior Authorization Criteria for Medicare HMO BlueSM (HMO) and Medicare PPO BlueSM (PPO) Plans Definition of Prior Authorization For certain drugs your doctor or
Source: rediff.com

Medicare HMOs reduce utilization, researchers say

“Although we could not assess the appropriateness of services, some of our findings suggest that the use of services may be more appropriate within Medicare Advantage HMOs,” the researchers said. “For instance, relative to beneficiaries in traditional Medicare, Medicare Advantage HMO enrollees are more commonly treated with cardiac bypass surgery, in accord with current guidelines. Additionally, lower rates of emergency department use suggest that Medicare Advantage HMOs may be treating patients in less costly primary care or urgent care settings.”
Source: lifehealthpro.com

Blue Cross & Blue Shield of NC Shows High Blue Medicare Ratings

[…] affordable BCBSNC blue advantage Blue Cross blue cross nc blue options Blue Options HSA coinsurance compare copay deductible dental blue dental insurance article dental insurance guide dental insurance information dental insurance tips finance health Health care health insurance health savings account Health Savings Accounts help with prescriptions high deductible health plan insurance Life Cover life insurance life insurance article life insurance guide life insurance information life insurance tips long term care insurance article long term care insurance guide long term care insurance information long term care insurance tips medicare NC North Carolina out-of-pocket ppo premiums rx help savings Term Life InsuranceSource: richdayhealthplans.com […]
Source: richdayhealthplans.com

Are you ready for 2013? 4 questions to ask yourself

Don’t forget, if you have Medicare Part B and are in Original Medicare, you’ll have to meet your deductible before your Medicare coverage pays for services and supplies. Next year, the Medicare Part B deductible will be $147. Make sure to plan your health care budget to account for the increased cost of doctor visits for the time that it will take to cover your deductible.
Source: medicare.gov

Carolina Family Practice & Sports Medicine

If you have questions about the Medicare plans we will accept in 2011, please talk with a member of our staff during your visit today or call our office at # 919-238-2000 option 3.  If you have any specific questions about your Medicare coverage or specific plan details, please call 1-800-MEDICARE or visit www.medicare.gov.
Source: cfpsm.com

O.C. HMO patients stuck in contract dispute

Blue Shield’s Davila said that, even after the termination takes effect, many patients will be able to keep their doctors because the doctors already belong to other medical networks contracted with Blue Shield or will join them. He said Blue Shield’s contract with Monarch applies to 16,800 customers in the commercial HMO market and 2,400 in Medicare.
Source: ocregister.com

Medicaid guidelines Arkansas

Posted by:  :  Category: Medicare

MORE DIRTY TRICKS FROM YOUR SOCIALIST/MARXIST   PRESIDENT AND HIS NASTY LITTLE ADMINISTRATION HACKS by SS&SSEach State provides medical assistance to its residents based on various criteria. Similarly the state of Arkansas also provides medical assistance based on criteria of age, income, disability, financial assets etc. There are certain guidelines released by the Arkansas State Medicaid department in order to become eligible for the medical assistance program. The individuals have to reach out to the Department of Human Services of the State.
Source: medicarearkansas.com

Video: Medicaid and Medicare: Too much income to qualify?

Get Ready For Enrolled Agent Education on New Medicare Tax on Investment Income

» All Local Guides » Alabama » Alaska » Arizona » Arkansas » California » Colorado » Connecticut » DC » Delaware » Florida » Georgia » Hawaii » Idaho » Illinois » Indiana » Iowa » Kansas » Kentucky » Louisiana » Maine » Maryland » Massachusetts » Michigan » Minnesota » Mississippi » Missouri » Montana » Nebraska » Nevada » New Hampshire » New Jersey » New Mexico » New York » North Carolina » Ohio » Oklahoma » Oregon » Pennsylvania » Rhode Island » South Carolina » South Dakota » Tennessee » Texas » Utah » Vermont » Virginia » Washington » West Virginia » Wisconsin
Source: fastforwardacademy.com

The American Spectator : Sequestration Depression

This is getting ridiculous, on both sides of the aisle. The lies are staggering from everybody in government. We are talking about a cut of $1.2 trillion over a 10 year period. This is a cut of $120 billion per year out of a yearly budget ranging from $3.2 trillion to $3.8 trillion per year (total projected expenditures over a decade of about $41 trillion). Even if we assume that Medicare, Medicaid and Social Security are off the table (47% of total budget in 2012), this is a budget cut of only 8.7%. For instance, this means a cut to Defense spending of about $52 billion per year. Hell people, Congress just passed a Sandy Hurricane relief bill that cost $60 billion spread over two years that was loaded with pork and payoffs to unions. The Pentagon says that they must furlough 800,000 civilian employees, if the average salary and benefits of these workers is only $70,000 per year, that alone will save $56 billion so that no other cuts would be required, but the Pentagon tells us (lies to us) and says we can’t even fuel our carrier fleets. If these dolts in Washington would ask everybody to sacrifice a little, they would demand proportional cuts in Social Security. For example a 3.0% cut to Social Security payments would save a total of another $19.2 billion or a reduction of monthly payments for a recipient receiving $2,000 per month of $60. We are being scammed by real political con men on every side.
Source: spectator.org

Maximizing your Resources and Saving Money: Medicare Savings Program

If you are on Medicare and have a limited income you may qualify for your state to pay your Medicare Part B premium. Eligibility in the program automatically qualifies you for extra help paying your Medicare Part D premium and prescription copayments. Check with your State for the requirements. Applications can usually be obtained online or at your local Social/Senior Services Center. Here are the following requirements in the State of CT:
Source: blogspot.com

Daily Kos: Projected Medicare spending falls dramatically

ferg, Gooserock, emal, Shockwave, Pescadero Bill, eeff, elfling, hnichols, Creosote, susakinovember, whenwego, pedrito, oceanview, splashy, antirove, psnyder, Eyesbright, wdrath, dkmich, Matt Esler, Vyan, ExStr8, marina, auditor, chimene, Alice Venturi, juliesie, YucatanMan, majcmb1, Inland, Savvy813, Ginny in CO, Jim R, Jim P, begone, martini, irishwitch, vigilant meerkat, luckydog, kck, blueoasis, shrike, JVolvo, Spock36, Dreaming of Better Days, Little, BentLiberal, bear83, peagreen, deepeco, joedemocrat, GeorgeXVIII, JML9999, TomP, cynndara, GAS, elwior, jamess, tofumagoo, petulans, Diogenes2008, clent, maggiejean, greengemini, shopkeeper, bfitzinAR, sfarkash, RoCali, Tortmaster, Larsstephens, Railfan, Christy1947, marabout40, Captain Marty, elginblt, anonevent, nirbama, ericlewis0, slowbutsure, OhioNatureMom, smiley7, PorridgeGun, BarackStarObama, createpeace, enhydra lutris, Canuck in Ohio, peregrine kate, VTCC73, Vatexia, jolux, jadt65, Inkberries, cwsmoke, Siri, wordfiddler, S F Hippie, This old man, rivercard, Olkate, Brown Thrasher, countwebb, JayRaye, howabout, doraphasia, The Story Teller, LilithGardener, northcountry21st
Source: dailykos.com

Medicaid Savings Illusory Under Obamacare Expansion, Critics Say : NC SPIN Balanced Debate for the Old North State

“The study assumes that new enrollees among old and newly eligible individuals will be cheaper than currently enrolled individuals,” Gokhale said. “But research shows that once insurance coverage is provided — in this case mandated — new enrollees quickly increase their use-intensity of health care services and become just as costly as those already enrolled into the program.” In other words, those enrolling in Medicaid who were not insured previously use health services just as much as those who already were in the program.
Source: ncspin.com

“Increasing the Social Security Payroll Tax Base: Options and Effects o” by Thomas L. Hungerford

The Social Security Trustees project that the assets in the two Social Security trust funds will be exhausted in 2033, and after that, Social Security payroll tax revenue will cover about three- quarters of promised benefits. To help close Social Security’s long-term financing gap, some analysts have proposed increasing the Social Security tax base by raising the maximum taxable limit so that 90% of aggregate covered earnings are taxable (the percentage in 1982). CBO estimated that the maximum taxable limit would have had to been $186,000 in 2008, almost double the actual limit, so that 90% of covered earnings are taxable. They estimated that this policy could have increased payroll tax revenues by $503.4 billion over the 2010-2019 period. The Urban Institute reports that the Social Security Administration estimates the 2012 maximum taxable limit would have had to been $214,500 so that 90% of covered earnings were taxable. Since 1982, the ratio of taxable earnings to covered earnings has fallen from 90%, reaching 82.7% in 2007. 82.7% in 2007.
Source: cornell.edu

WHAT IS THE PACE PROGRAM?

Interdisciplinary teams of doctors, nurses, social workers, therapists, nutritionists, personal care attendants, and other medical staff work together to provide all needed medical and supportive services to maximize a participant’s ability to remain in his or her home for as long as possible.  Care and services include: primary medical care, home health care, adult day health, rehabilitation services, nursing services, hospital care, restorative therapies, personal care and supportive services, nutritional counseling, recreational therapy, meals, transportation, medications, podiatry, optometry, dental, social services, and anything else the program determines is medically necessary to improve and maintain the participant’s overall health.  Services are available 24 hours a day, 7 days a week, 365 days a year.   Generally, the majority of PACE services are provided at an adult day center, but these services may be provided in the home when appropriate.  If the time comes when nursing home placement is necessary, PACE would pay for the nursing home costs and would continue to supervise the member’s care, so long as the member resides in a PACE facility.
Source: massestatelawyer.com

Lab Soft News: Medicare Costs Rise as Knee Replacements Increase for Seniors

Posted by:  :  Category: Medicare

Friends of Medicare Healthcare Rally by dave.cournoyerThe popularity of total knee arthroplasty surgeries among Medicare patients has grown considerably as beneficiaries are living longer and seeking to increase their mobility, but the shift has led to fiscal concerns for the entitlement program….Overall volume growth has been driven both by the increased number of Medicare enrollees and by increased per capita utilization….The number of total knee replacements increased 161.5% between 1991 and 2010, when 243,802 such surgeries were performed. Per capita utilization nearly doubled during that period, to 62.1 procedures per 10,000 Medicare beneficiaries from 31.2 surgeries per 10,000 enrollees….For patients, knee replacements are relatively safe and have low rates for complications, mortalities and length of hospital stays. However, 30-day readmissions rates have risen to 5% in 2010 from 4.1% in 1991. Shorter hospital stays are causing the increase, a change that should have been expected by health policymakers….The volume of revision knee replacement surgeries has increased to 19,871 in 2010 from 9,650 in 1991….There were 243,802 knee replacement surgeries in 2010, a jump of 161.5% from 1991. More and more patients taking advantage of the surgeries will lead to higher Medicare program costs. The procedure itself costs about $15,000 to $30,000…The bundled Medicare payment for the procedure is spent on the device implants, facility fees, therapy providers and the surgeons. The surgeon probably will receive about $1,500 of the total….New Medicare payment models, such as the bundled payments used for knee replacements, aim to achieve lower costs while maintaining high quality to prevent patients from being readmitted.
Source: typepad.com

Video: 2010 Medicare Quote Engine Demonstration Video

Melgen, Menendez throw spotlight on Medicare, Medicaid fraud

“Normally, federal searches of businesses occur during the day during normal business hours. The fact that this search began on Jan. 29 and lasted some thirty-plus hours and ended Jan. 30, tells us the scope of this search was major,” Ken Boehm, chairman and cofounder of the National Legal and Policy Center, said by email. “Also, the presence of crow bars and drills would seem to indicate that materials being sought were locked up. By any conventional yardstick, all of this activity tells us this is a very serious investigation.”
Source: freebeacon.com

Communities of Care Model Saves $5 Million In Hospital Costs

The JAMA study focused on 14 communities around the country, where researchers found that interventions helped to avert about 6,800 hospitalizations and 1,800 re-hospitalizations per year. In a hypothetical average community of 50,000 fee-for-service Medicare beneficiaries, the collaborative effort would have saved Medicare more than $4 million per year in hospitalization costs, while costing less than $1 million to implement, the study authors said. However, the study found no change in the rate of re-hospitalizations as a percentage of all hospital discharges.
Source: courant.com

Obama’s Proposals For Medicare — Do They Go Far Enough? Will They Become Law?

Why has Medicare been overpaying Advantage insurers? Under the Medicare Modernization Act (MMA) of 2003 Congress agreed to pay Advantage Insurers 13% more than it would cost traditional Medicare to cover the same seniors.  Since then research has shown that seniors themselves didn’t believe that Advantage is worth the premium.  A 2009 study published in the International Journal of Health Care Finance and Economics reveals that, when Advantage beneficiaries were asked how much they would pay, out of their own pocket, for the benefits provided by their insurer, they estimated the value of those benefits at just 14 cents for every extra dollar that Medicare was paying. The Incidental Economist’s Austin Frakt, a coauthor of the report, concluded: “This relatively poor return of value on taxpayer dollars is why I support reductions in Advantage payments.”
Source: healthbeatblog.com

Romney draws on 2010 playbook in Medicare offensive

We have the segment of society that cannot afford private insurance (either by earning too little or by having too many other obligations) but also earn too much to qualify for government sponsored care through Medicaid. These people fall into two groups–group one goes to the doctor and pays for the services they receive, while group two goes to the doctor and does not pay for the services they receive. This second group of this segment of population has been claimed by many to be the reason why an enforcement of insurance use by all is necessary, as the doctors and hospitals claim to have raised prices to the insured to cover the cost of “deadbeats”. There are two problems with this idea: 1. Doctors and Hospitals admit to be steeling funding from guaranteed payers in order to cover the cost of the deadbeats, and 2. A vast majority of these deadbeats simply cannot afford to pay for the care because the costs are entirely too high–it is not that they choose to be sick and to cheat the system by walking away from their bills–and the costs are too high because the hospitals and doctors continue raising prices on the payers in order to cover those who can’t pay. We have to ask the question, will guaranteeing more payers (there will still be those who cannot be guaranteed) cause the costs to go down? It is doubtful, as the wages earned by those in the healthcare industry are some of the only wages that have outpaced ordinary inflation, so they are used to a certain lifestyle. Further we should ask the question, will guaranteeing more payers to a group that has proven itself to misuse their trusted position by dubiously increasing costs on people who could pay to offset losses and make extraordinary profits that allowed them such greater wage benefits as the vast majority of the rest of society, make that group somehow more trustworthy–ie will prices then stabilize, defying supply and demand (as supply of everything medical will decrease while demand will increase, which usually results in increased prices)? Furthermore we must recognize that the people who go bankrupt because of the cost of health care are the truly ill of this group and the group of employer-insured people above (not the privately insured as they obviously earn a good deal of money in order to afford private insurance). These people earn too much to qualify for medicaid. We can raise the medicaid floor, however the medicaid floor must remain at pace with wages. OR We can determine a way to bring cost of care back in line with overall costs and wages, so that care and insurance both become more affordable to everyone. This would probably mean the FTC or some entity like that coming down hard on doctors and hospitals for arbitrarily increasing cost of care to people not receiving the care, which sounds a lot like theft.
Source: nbcnews.com

New AMIC Survey Data Shows 2010 Medicare Payment Cuts Forcing Physician Practices and Imaging Providers to Reduce Patient

In the past, the Obama Administration has proposed using RBMs in the Medicare program.  However, the Department of Health and Human Services (HHS)  previously weighed in on prior authorization in the Medicare program, noting in 2008 that a prior authorization program could be “inconsistent with the public nature of the Medicare program,” since such programs rely on private companies using proprietary systems to deny care prescribed by a physician.  HHS also noted that the Medicare appeals process guaranteed to every beneficiary could overturn a “high proportion” of denials, rendering the policy ineffective.  In an environment of reduced reimbursements, the AMIC survey further demonstrates that application of RBMs is an ineffective model imposing unnecessary administrative costs on practices, thereby creating artificial barriers for patients in need of care.
Source: rightscanrighttime.org

Providers Filed 85% of Medicare Appeals in 2010

A study from the HHS Office of Inspector General (pdf) found that hospitals and other Medicare providers filed 85 percent of payment appeals at the administrative law judge level, 56 percent of which went in favor of providers, and the OIG concluded that serious improvements are needed to clarify Medicare policies. Medicare providers and beneficiaries may appeal certain decisions regarding claims for healthcare services. For example, hospitals may appeal payment recoupments from Recovery Auditors, or RACs, if they believe their actions were consistent with Medicare law and standards. There are four general levels of appeal: Level One goes to CMS Medicare Administrative Contractors, Level Two goes to CMS Qualified Independent Contractors, Level Three goes to ALJs and Level Four goes to the Medicare Appeals Council. The ALJ level is the most common platform of the four. The OIG looked at the 40,682 Medicare appeals filed to ALJs in fiscal year 2010. It found that hospitals, physicians and other providers filed 34,542 of those appeals, or roughly 85 percent. In addition, a small number of providers accounted for nearly one-third of all appeals. The OIG tagged 96 providers as “frequent filers,” meaning they filed at least 50 appeals each. One provider filed 1,046 appeals alone. For 56 percent of appeals that made it to level three, ALJs also reversed 56 percent in favor of appellants, indicating a “number of inconsistencies and inefficiencies in the Medicare appeals process,” according to the OIG’s report. The OIG had 10 recommendations for CMS and the Office of Medicare Hearings and Appeals, including more coordinated training on Medicare policies to ALJs and QICs, better identification and clarification of Medicare policies that are unclear, and digitization of appeal case files. CMS and OMHA concurred fully or in part with all of the OIG’s recommendations.
Source: beckershospitalreview.com

Seniors Need To Be Tenacious In Appeals To Medicare

Medicare officials say appeals are rare, though they would not provide statistics on how many appeals came from beneficiaries rather than from health-care providers, such as hospitals, doctors and nursing homes.  The inspector general’s office in the Department of Health and Human Services reported last month, however, that 85 percent of appeals in 2010 that reached the third level of review, which are decided by an administrative law judge, were filed by health care providers.  And for those who persevere and do appeal a third a third time, the OIG found that the judges reversed 56 percent of all unfavorable decisions in 2010.
Source: kaiserhealthnews.org