Medicare GAO Report on Radiology

Prior Imaging-Authorization Suggested
Staff Reporters
As reported in the Wall Street Journal, on July 14, 2008, Medicare may be soon requiring prior authorization to curtail unnecessary utilization of CT scans, MRIs and other forms of medical imaging, a new Government Accounting Office [GAO] report suggests.
The Medicare Report
To cut imaging costs, Medicare has been reducing certain physician [...]

Patients Challenging Medical Invoices

Root Cause is Money, Failure-to-Disclose and Frustration
Staff Reporters
Patients are challenging their medical bills with lawyers and lawsuits, out of frustration about the lack of up-front disclosure over costs by doctors and hospitals.
Involve More than a Few Cases
For example, after being charged $82,282 for a 23-hour stay in doctor-owned Westfield Hospital for two operations on [...]

Blue Cross - Blue Shield Administrative Survey

Cost Trends Demonstrate a Decline in 2007
By Douglas B. Sherlock; CFA
PRESS RELEASE REPORT
Gwynedd, Pennsylvania
The per-member [pm] administrative cost growth for BC/BS declined from 6.1% in 2006, to 4.3% in 2007. Adjusted to eliminate the effect of a shift in product mix, administrative expense growth declined from 6.5% in 2006 to 2.5% in 2007. Administrative expenses [...]

CMS to Bonus Doctors for PQRI

July – December 2007 Reporting Period
Staff Reporters
According to Anne Zieger, of Fierce Health Finance, the Centers for Medicare and Medicaid Services [CMS] will pay out more than $36 million in monetary incentives to medical providers who reported data on quality of care delivered between July 2007 and December 2007; as part of its Physician Quality [...]

RAC Contractors to be Identified

CMS Aims to Reduce Fraud
Staff Writers
This month, the Centers for Medicare and Medicaid Services [CMS] will name the auditing firms that will review hospitals’ books for payment mistakes, while hospital officials say results in other states suggest the auditors will give priority to recovering overpayments.
The RAC Program
Under the so-called Recovery Asset Contractor [RAC] program, [...]

Doctors Unite!

On the “Open Letter from America’s Physicians”
By Dr. David Edward Marcinko; MBA, CMP™
Publisher-in-Chief
As we have seen in this healthcare-charged election season, almost every form of political activism or debate has moved online. So, it is no surprise that a coalition of disgruntled physicians would electronically socialize and network together, as seen with www.sermo.com
About Sermo - Peer [...]

The Cure for Claims Campaign [CCC]

Reducing Healthcare Administrative Burdens and Costs
Staff Writers
To help reduce the administrative burden of ensuring accurate insurance payments for physician services, the American Medical Association [AMA] recently launched the “Cure for Claims” Campaign [CCC] and unveiled the first AMA National Health Insurer Report Card on claims processing.
Goals
The goal of the AMA campaign is to hold [...]

Hospitals Auctioning Patient Debt

Online Sale of Patient ARs
Staff Reporters
In another sign of the contracting economic times, FierceHealthFinance is reporting that some struggling hospitals are using the internet as a new channel to cut their write-offs, and bad debt ratios which lower stock prices, if publicly-held.
Exit the Debt Collectors – Enter the Auctioneers
Rather than simply hiring agencies [...]

Paying for Health Care and Insurance

New Survey Reveals 28% Report Financial Problems
Staff Reporters
A new survey by the Kaiser Family Foundation recently asked this question.
Q: As a result of recent changes in the economy, have you and your family experienced any of the following problems, or not? Was this a serious problem, or not?
A: Results are included in the summarized [...]

Patients Desperately Seeking EMRs

A New P4P Twist?
Staff Reporters
The Department of Health and Human Services [DHHS] recently received more than 30 applications from communities seeking to participate in a Medicare pilot program that uses electronic health records [EHRs]; according to CQ HealthBeat reports.
Pilot Program
Under the new experimental pilot program, DHHS and the Centers for Medicare and Medicaid Services [...]

Reimbursing Acute Care Episodes

A Proposed New ACE Payment Scheme
Staff Writers
Did you know that the Centers for Medicare & Medicaid Services [CMS] announced a planned demonstration project last week that would combine payments for both hospital and physician services for a select number of episodes of care? Its intent is to determine if such an approach will be more [...]

Health Plans Financially Squeeze Providers

Patients Squeezed, Too!
Staff Reporters
As regular readers of the “Executive-Post” know, several leading health plans have taken a profitability beating over the last several months. The reasons for the economic decline include operational issues, rising medical costs and financial market losses. For example, WellPoint, missed Wall Street’s estimates by a wide margin making financial analysts more [...]

AIM Report on LOS

Briefer Hospital Stays not Always Better
Staff Writers
Briefer hospitalizations are not always best, according to a recent new study published in the Archives of Internal Medicine [AIM].
The PHCCC Study
A study of 15,531 patient medical charts, using hospital billing data from the Pennsylvania Health Care Cost Containment Council [PHCCCC], found that patients diagnosed with a pulmonary embolism [...]

MS-DRG Classification System

Upgrading the DRG Scheme of the Mid-Nineties

Dr. David Edward Marcinko; MBA, CMP™
Publisher-in-Chief 

The Centers for Medicare and Medicaid Services [CMS] just adopted as final its proposal to restructure the older 538 Diagnosis-Related Groups (DRGs) to 745 new MS-DRGs (Medicare Severity-adjusted Diagnosis Related Groups) to better recognize severity of patient illness. 
According to the CMS and the consulting [...]

Medicare Costs to Double by 2017

New CMS Report for 2008
Staff Writers  
According to a new CMS report, national health spending grew 6.7% last year, reaching $2.2 trillion overall. But, it is expected to hold steady over the next 10 years. 
Nevertheless, healthcare spending will account for 20% of GDP by 2017; if left unchecked.
Of course, more than a few health economists [...]

Explaining MS-DRGs

New CMS Healthcare Finance Rules for Fiscal 2008
By Dr. David Edward Marcinko; MBA, CMP™
Publisher-in-Chief 
 
The Centers for Medicare & Medicaid Services (CMS) just released the final Inpatient Prospective Payment System [IPPS] rules for fiscal year 2008. The lengthy official version was published in the Federal Register on August 22, 2007.
The good news is that overall Medicare [...]

Traditional Methods of Healthcare Finance

A Brief Historical Review of Delivery
Dr. David Edward Marcinko; MBA CMP™
Publisher-in-Chief 
 
Prior to 1970s, the healthcare reimbursement system was not a monolithic complex and most Americans received their healthcare through one of five third-party organizations:  (1) Blue Cross/Blue Shield (pre-paids), (2) Commercial insurance (private) companies, (3) Medicare (federal-elderly), (4) Medicaid (state-poor) and (5) CHAMPUS (military).  
Four Fragmented [...]

Non-Profit Hospitals and CEO Salary

The Connecticut State Challenge
Staff writers 
 
The state of Connecticut has 31 hospitals that are economically struggling.
The Report 
In fact, according to a 2006 report - led by Governor M. Jodi Rell - more than half of the state’s non-profit hospitals ran deficits while the rest generated below-adequate surpluses. Financial help has been slow from the state’s insurance [...]

National Physician Expenditures Slow

A CMS Health Economics Report
Staff Reporters 
 
The Centers for Medicare and Medicaid Services [CMS] recently reported that while the national health spending growth rate increased slightly in 2006, the percentage rise in expenditures on physician services slowed markedly, due largely to a small Medicare pay increase and its private-sector fallout. 
Overall national health spending reached $2.1 trillion, [...]

Capitation “ReDux” - Part Two

Global Physician “Capitation” Payments Making a Comeback
Staff Reporters
 
Did you know that Blue Cross and Blue Shield of Massachusetts is making a major change in the way it pays its physicians?
It’s moving from [discounted] fee-for-service payments to per-patient per-year capitation rates, adjusted for age and sickness (severity adjustments), plus a bonus for those MDs who [...]

2008: Prognostications from Healthcare Financials

SPECIAL REPORT:
A Medical “Executive-Post” Op-Ed Essay
Dr. David Edward Marcinko; MBA, CMP™
Publisher-in-Chief
 
A new heuristic study by the Institute of Medical Business Advisors Inc [www.MedicalBusinessAdvisors.com] and [www.HealthcareFinancials.com] suggests that the New Year 2008 could be a big one for the healthcare industrial complex - with these dozen economic observations and postulated structural changes that could profoundly affect [...]

“Never-Events” Payment Trends

Aetna and WellPoint Refuse to Pay for Medical Errors
Staff Writers
 
According to The Wall Street Journal, some large private health insurers are following Medicare’s lead by refusing reimbursement for erroneous medical care. Aetna and WellPoint now have contract provisions stating their refusal to pay – or allow patient-balance-billing – for care related to the 28 “Never-Events” [...]

Medicare Spending Increases [New Study]

A New CMS Report
Staff Writers 

The Centers for Medicare and Medicaid Services recently reported that expenditures increased at the fastest rate in 25 years, fueled by its new Part D drug benefit. 
The CMS study found that health spending totaled $2.1 trillion in 2006 - or 16 percent of gross domestic product - up 6.7 percent from 2005, [...]

Medicare Payments to Improve in 2008

Physicians Receive Temporary Reprieve
Staff Writers 

Doctors will get a six-month reprieve from a 10.1 percent across-the-board cut in Medicare payments that was scheduled to go into effect January 1, 2008. 
In an effort to secure approval of the legislation, lawmakers decided to scale back its scope compared to earlier versions of the measure, but the bill still [...]

Ambulatory Payment Classes [APCs]

Understanding Outpatient Payment Schemes
Dr. David E. Marcinko; MBA, CMP™
Hope R. Hetico; RN, MHA, CMP™ 

Some physicians are still unaware of the Medicare payment regulations implemented a few years ago regarding outpatient or ambulatory care.  
Ambulatory Payment Classifications (APCs), originally termed Ambulatory Payment Groups (APGs), replaced former cost based, or cost plus reimbursement contracts for outpatient [...]

Toward a National Healthcare System

EEOC Health Benefit Reductions and Eliminations
Staff Writers 
 
The Equal Employment Opportunity Commission issued a new policy in December 2007 stating that employers can reduce or eliminate health benefits for retirees when they turn 65 years old and become eligible for Medicare.  
The new regulation allows employers to establish two classes of retirees, with more comprehensive benefits for [...]

Medicare - Simply Unsustainable

Medicare and Medicaid Spending Growth
Staff Writers 
 
Like Michael Palmer’s song, “Irresistible”, it seems that Medicare and Medicaid spending would — if unaddressed — continue to grow faster than the economy over the next 75 years. According to the Congressional Budget Office; it’s also very unsustainable. 
The culprits are physician and hospitals reimbursement methods and new technology and [...]

Pay-for-Performance Blunders

P4P Confusion Reigns
Staff Writers 

The Minnesota Medical Association recently reported that its P4P initiatives create confusion and unnecessary administrative work for medical providers.
The association looked at programs by Blue Cross and Blue Shield, Bridges to Excellence, HealthPartners, Medica, PreferredOne, UCare and the CMS; complaining that the nine pay-for-performance programs used by state insurers each have subtle [...]

New CMS Premiums and Deductibles

2008 Medicare Part A and B
Staff Writers 
 
CMS annually updates Medicare Beneficiary premiums, deductibles and co-payments, using formula driven adjustments set by statute.
As a reminder, Medicare Part A pays for inpatient hospital, skilled nursing facility and some home health care and Part B refers to outpatient expenses and pays doctors. About 99 percent of Medicare beneficiaries [...]

CMS and the Economic S.G.R for 2008?

CMS to Docs … Payments to Drop!
Staff Writers
 
According to Modern Physician, November 1, 2007, Medicare payments to physicians in 2008 will drop nearly 10 percent under a final rule issued by CMS, which estimates it will pay approximately $58.9 billion to 900,000 physicians and other health care professionals next year. The sustainable growth rate formula, [...]