Monthly Archives: August 2016

CMS to End ICD-10 Coding Flexibility for Medicare Providers

One of the concessions CMS made to the provider community last year in an attempt to quell anymore calls for further ICD-10 compliance date delays was to provide a one year grace period from claims rejection if the ICD-10 filed on the claim was not coded to the highest specificity.  That did not mean the provider could just slap on any diagnosis code (e.g. a generic diabetes diagnosis when the patient presented w/a stubbed toe and was not diabetic) as the provider still had to have accurate medical documentation from the encounter.  The provider had to be w/in the family of codes.  For instance, in the above diabetes example, the provider could possibly code w/in the diabetes category (the first three digits of the diagnosis code) but not drill down to the most specific code based on the encounter.

The one year grace period is coming to an end.  CMS has announced an update to the Q&A where they announced the coding flexibility last year.  There is no leeway on extending this.

Read more here.

Iowa’s Switch to Medicaid Managed Care: The Scorecard for the First 6 Months

Increasingly, states are moving to private payers to provide care for their Medicaid population.  Earlier this year, Iowa was one of the markets that went live w/three insurers (AmeriHealth, Amerigroup, and United Healthcare) that provided managed care for poor and disabled Iowans.  How is it going?  Two of the three payers are reporting significant losses (AmeriHealth-$42.6 million, Amerigroup-$66.7 million) while United has not yet reported financial data at this time.  All three payers have made signficant monetary investments to start-up the Iowa plans and put in necessary infrastructure, these losses suggest members are utilizing healthcare services more than anticipated and are also sicker.

The question remains whether moving to managed care contracts will actually save the state government money in the long run.  If these losses continue, it is extremely likely the insurers will attempt to renegotiate premium rates to further adjust to actual costs of servicing these members or could potentially pull out of Iowa all together.

Read more here.

Turmoil in ACA Markets as Insurers Leave

Several large insurers including Aetna, United Healthcare, and several Blue Cross plans recently have either announced or have threatened to pull out of several ACA exchange markets due to higher than expected expenditures servicing members.  What does this mean for the health and future of the Affordable Care Act?  Most of the insurers will remain in large metropolitan areas but the future of providing individual policies to vast parts of rural areas seem to be the most at risk.

Read more here.

The Reinsurance Program Affiliated w/the Affordable Care Act is Slated to End Soon

One of the main tenets of the Affordable Care Act is the reinsurance program that was created to help alleviate participating insurers’ concerns about adverse selection for members that could no longer be denied for preexisting conditions nor the newly insured that were highly likely to drive up claims expenditures.  For the 2014 benefit year, the first full year of insuring members through the Affordable Care Act, insurers were paid $7.7 billion.  A similar amount was slated for last year’s coverage period.  However, this is a temporary program that is only slated to last three years.  Will its absence cause more insurers to leave and potentially weaken the healthcare marketplace?