nnHappy Thanksgiving from all of us at Welter Healthcare Partners. We want to thank our partners and clients for their continuous support and business throughout the year. We are so grateful to you. We wish you a safe holiday with your loved ones.nnOvereating (R63.2) is defined in medical terms as “to eat to excess, especially when habitual.” Break the habit of this holiday and save some leftovers for tomorrow.nn
After months of feedback from payers and providers unhappy with a proposal to mandate price transparency in healthcare, the Trump administration has now unveiled its final rule on the topic of hospital price transparency. This topic has been in talks for months and its effective date is being pushed to 2021.nnnDeclaring “a major victory” for patient choice and affordable healthcare, President Donald Trump on Friday unveiled his administration’s final rule on hospital price transparency.nn”I don’t know if the hospitals are going to like me too much anymore with this, but that’s OK,” Trump said at a White House event to announce the rule.nn”We’re stopping American patients from just getting, pure and simple, two very simple words: ripped off. Because they’ve been ripped off for years, for a lot of years,” he said.nnThe final rule—which takes effect on January 1, 2021, one year later than initially proposed—requires hospitals to provide patients with easily accessible information about standard charges for items and services offered.nnThis includes making all standard charges available in a single data file that can be read by other computer systems, as well as making “shoppable services” information available on their websites in a consumer-friendly manner.nnAdditionally, hospitals must make information about shoppable services, which can be scheduled by patients in advance, available in a “prominent location online” and describe the information in plain language.nnThe Centers for Medicare & Medicaid Services also issued a separate proposed rule that would impose price transparency requirements on health insurers.nn”I’m sure they’ll be thrilled,” Trump said of insurers. “This will allow you to see your out-of-pocket costs and other vital price information before you go in for treatment, so you’re going to know what it’s going to be and you’re going to be able to have lots of choices, both in terms of doctors, hospitals, and price.”nnThe final rule provides CMS with additional enforcement and auditing capabilities, including the ability to issue monetary fines of $300 per day for hospitals that don’t comply.nnThis announcement came less than four months after CMS released its proposed rule on hospital price transparency.nnHealth and Human Services Secretary Alex Azar applauded the president for implementing “revolutionary change” to the healthcare system.nn”Today’s transparency announcement may be a more significant change to American healthcare markets than any other single thing we’ve done, by shining light on the costs of our shadowy system and finally putting the American patient in control,” Azar said.nn
Hospitals Say They’ll SuenNot surprisingly, payer and provider stakeholders responded to the new final rule with a chorus of boos and promises of litigation.nnIn a joint statement, the American Hospital Association, Association of American Medical Colleges, Children’s Hospital Association, and Federation of American Hospitals called the proposed rule “a setback in efforts to provide patients with the most relevant information they need to make informed decisions about their care.”nn”Instead of helping patients know their out-of-pocket costs, this rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers, and stymie innovations in value-based care delivery,” the hospital groups said.nn”Because the final rule does not achieve the goal of providing patients with out-of-pocket cost information, and instead threatens to confuse patients, our four organizations will soon join with member hospitals to file a legal challenge to the rule on grounds including that it exceeds the Administration’s authority,” the hospitals said.nnBeth Feldpush, senior vice president of policy and advocacy at America’s Essential Hospitals, said the final rule “would unfairly advantage health plans in negotiations with providers and threaten essential hospitals’ ability to participate in networks and maintain access to services.”nn”Information without context—for example, how and why the cost of patient care varies among hospitals—is of little practical use to consumers,” she said. “Essential hospitals typically have higher costs due to their commitment to complex services vital to communities, such as trauma and behavioral health care.”nnAlso, Feldpush said the final rule would create an administrative nightmare for hospitals that would hurt patient care and drive up costs.nn”These policies undermine hospital’’ ability to negotiate equitable payments while giving consumers little actionable information with which to make informed care decisions,” she said.nnOn the payer side, Matt Eyles, president and CEO of America’s Health Insurance Plans, said price transparency “should aid and support patient decision-making, should not undermine competitive negotiations that lower patients’ health care costs, and should put downward pressure on premiums for consumers and employers.”nn”Neither of these rules—together or separately—satisfies these principles,” he said.nnOriginal article published on healthleadersmedia.com
Opioid Treatment Programs (OTP’s) have been a hot topic for several years. Among several new codes set to be implemented January 1st are new HCPCS codes specifically for OTP’s. nnHere are two sequences to be aware of:nGYYY1-GYYY3 (office-based treatment)nGXXX1-GXX19 (medication-assisted treatment)nnThese new codes will reimburse with bundled payments for the treatment of opioid use disorder (OUD). Refer to CMS Provider Type Opioid Treatment Program for enrollment and to learn more about the proper use of these new codes.
Since acquiring PillPack in 2018, Amazon has now bought Health Navigator in which they intend to offer to employees of Amazon. Many are certain Amazon will soon enter the healthcare market. Read the article below to find out more about this new acquisition that was made and learn some of Amazon’s goals.nnIn what is its first healthcare-related acquisition since spending $753 million in June 2018 to acquire PillPack, Amazon.com (NASDAQ: AMZN) inked a deal to buy Health Navigator, a start-up that provides digital triage tools and symptom lookup. The value of the deal was not disclosed.nnAmazon intends to offer Health Navigator services to its employees, shedding further light on where the e-commerce giant is heading in the healthcare market.nnIn late October, Amazon confirmed it purchased Health Navigator, telling CNBC it will fold it into Amazon Care, its new employee healthcare benefit that gives users access to virtual doctors and nurses. The idea is to leverage technology so employees can access healthcare providers in a convenient manner and at a lower cost. In addition to accessing virtual doctors and nurses, Amazon Care users (currently limited to employees in the Seattle area) can fill prescriptions through the e-commerce giant and choose between having them delivered or picked up at a participating pharmacy. By providing healthcare services to its employee base Amazon gets to test the waters and make fixes before the program is offered to a wider market. That serves to keep costs down and prevent it from making missteps on a large scale basis.nnAmazon hasn’t laid out all its plans in the healthcare market, but the acquisitions and initial products coming out of its healthcare joint venture with JPMorgan Chase (NYSE: JPM) and Berkshire Hathaway (NYSE: BRK-A)(NYSE: BRK-B) are starting to provide an outline for what it wants to do.nnCutting costs, increasing accessibility is Amazon’s goalsnAt the heart of Amazon’s aspirations is cutting the costs and challenges associated with healthcare, whether that means managing the price of medicine or increasing accessibility to doctors and nurses. In January 2018, it teamed up with JPMorgan Chase and Berkshire Hathaway to offer employees medical insurance. Now called Haven Healthcare, the group is gearing up to roll out its first products: two health insurance plans employees can begin to tap in 2020. The plans include free preventive care, no coinsurance or deductible, and $15 co-pays. This is the first product out of the secretive Haven Healthcare, but it showcases how Amazon and its partners are focused on lowering costs of medical care and insurance.nnThe acquisition of Health Navigator also helps Amazon achieve the goal of lowering the expenses associated with healthcare. Health Navigator’s technology is aimed at making it cheaper and easier to receive medical care. Microsoft is one of its many customers, providing the software giant with a clinical vocabulary and symptom checker technology to power a health bot. The bot uses layperson language to ask patients about their symptoms, ask relevant follow-up questions, and provide care options and potential causes. That eliminates the need for the sick employee to take time off from work, spend the money to get to the doctor and then wait in the office, for hours in some cases, to be seen. The bot can determine if it’s something as basic as a common cold and prescribe an over-the-counter remedy. A slew of telemedicine companies also uses Health Navigator’s technology.nnAmazon wants it alln
For some time now, Amazon has been laying the groundwork to enter the healthcare market, which is massive at $3.5 trillion and in need of some disruption. What better company to do it — Amazon has already changed retail and the way millions of people shop. While it’s been cagey about its intentions, many have speculated about what it will look like. Some think Amazon will disrupt the pharmacy market, dealing a direct blow to the likes of Walgreens and CVS Health. Others think it wants to own the telemedicine market, coming for the likes of Teladoc Health. But CB Insights, a market research company, thinks Amazon wants it all. It also thinks the retail giant has the size and reach to get just that.nnFor investors, These healthcare-related efforts may mean a new area of revenue growth at a time when Amazon is warning it could be slowing. For its fourth quarter, Amazon is projecting revenue of between $80 billion and $86.5 billion, which is lower than the $87.4 billion analysts were expecting. That comes even though the quarter includes the holiday shopping season. The healthcare market is also a huge opportunity to diversify further for the eCommerce giant.nn”Amazon’s potential foray into healthcare has already caused players in the space to scramble and reevaluate their core competencies. While Amazon has barely scratched healthcare’s surface, it has the potential to upend the space with its e-commerce expertise,” wrote CB Insights. “Without the need to make money in healthcare, the high margin and convoluted parts of the healthcare business are ripe for disruption.” All of which means there’s another bastion of growth Amazon can hang its head on if eCommerce growth levels off.nnOriginal article published on fool.com
Although the exact reason for denial was not given for this encounter we know this is considered investigational. Most insurances will not pay, it would have to be unlisted-23929. Click below for more information!nnnAs a general rule, benefits are payable under Blue Cross and Blue Shield of Alabama health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.nnThe following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:n
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nMedical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptomsnnClick to read the full PDF from Blue Cross Blue Shield of AlabamannThe following coverage policy applies to health benefit plans administered by Cigna. Coverage policies are intended to provide guidance in interpreting certain standard Cigna benefit plans and are used by medical directors and other health care professionals in making medical necessity and other coverage determinations. Please note the terms of a customer’s particular benefit plan document may differ significantly from the standard benefit plans upon which these coverage policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a coverage policynnClick to read the full PDF from Cigna, regarding reasons for denials when an encounter is considered investigational.nn
State healthcare officials have until November 15 to put together a final “state option” proposal for the legislature. Many are hoping new changes will be implemented due to the rise in healthcare costs. Read the article below to find out more on what legislation may be coming and what the concerns are with this program.nnIn what is shaping up to be the major health care battle at the state Capitol this coming legislative session, Colorado hospitals, and insurance companies both have raised concerns about a proposal to dictate hospital prices for a slice of people with private health coverage.nnThe idea, unprecedented across the country in its precise details, is part of an ambitious plan to create what Colorado health officials are calling a “state option” insurance program. The program would aim to lower insurance costs for people who buy coverage on their own.nnIt would largely achieve those lower rates by limiting how much hospitals can charge people covered by state option plans, which would be sold and administered by private insurance companies. Both hospitals and insurance companies would likely be required to participate in the program, though state officials have been vague on whether they have the authority to compel participation or whether they would need to ask the legislature for that authority.nnEither way, the state-option proposal has found hospitals and insurance companies — frequent foes in the battle over health costs — sharing unusual common ground.nnThe hospitals’ opposition is fairly simple to understand. They don’t want the government telling them what their prices can be.nn“Fundamentally, we as an organization are opposed to rate-setting,” said Katherine Mulready, the chief strategy officer for the Colorado Hospital Association. She said the proposal “misses the mark” and that its architects should return to the drawing board.nnBut the Colorado Association of Health Plans, the organization that represents health insurance companies in the state, also has raised concerns about the proposal, echoing two of the hospitals’ objections, though it supports the push to bring down the underlying costs of health care.nnFirst, insurers and hospitals say the program could make health insurance provided by employers more expensive. Why? Because hospitals might make up for the money they’re not getting for patients with state-option coverage by charging people with employer-sponsored coverage more.nnThe hospital association says this “cost shift” could be $1.5 billion over five years. (State officials argue that hospitals have already — and needlessly — shifted billions in costs onto the privately insured even as they have reaped record profits.)nn
“This one-size-fits-all approach would have the effect of increasing costs for employers,” Amanda Massey, the executive director of the Colorado Association of Health Plans, wrote in an emailed statement.nnSecond, both hospitals and insurers say patients could suffer by not having access to doctors. Hospitals warn that cuts to their bottom lines could lead to cuts in staffing. Insurers say private doctors’ offices, which wouldn’t be forced to accept the coverage, might choose not to see patients with state-option insurance.nn“The result will be reduced patient access to adequate networks and quality care,” Massey said.nnThe goal behind the state option — sometimes called the public option, even though the government wouldn’t administer the plans in Colorado’s proposal — is to ensure more choices and better prices for people who don’t get health coverage through their jobs. That group currently makes up about 7% of Coloradans.nnGov. Jared Polis has frequently touted the state option and reducing hospital prices as part of his “road map” for saving Coloradans money on health care.nnThe two-state officials putting the plan together — Kim Bimestefer, the executive director of the state’s Department of Health Care Policy and Financing, and Michael Conway, Colorado’s insurance commissioner — have in recent weeks held meetings across the state seeking input on their plan. They have also received more than 200 written comments.nnThe final proposal is due to the legislature by Nov. 15.nnOriginal article published on coloradosun.com