Compliance Resources to Help you Stay Current

Consumers who meet the criteria for Medicaid or those who are looking for health insurance now benefit with the announcement from the U.S. Department of Health and Human Services (HHS) providing states with a simple and seamless enrollment experience for health insurance in state exchanges. This comes under the Affordable Care Act.

On October 13, 2010, President Obama signed S 3397, the Secure and Responsible Drug Disposal Act of 2010. S. 3397 was considered on the House floor on September 29, 2010, under a suspension of the rules, requiring a two-thirds majority vote to pass. The Act was introduced by Sen. Klobuchar (D-MN) on May 24, 2010, and it passed the Senate by unanimous consent on August 3, 2010.   

With the mission to recover erroneous Medicare payments paid to the healthcare providers under Free-for-Service Medicare plans, the Recovery Audit Contractor program was launched through the Medicare Modernization Act of 2003. However, this program became permanent for all states in Jan 1, 2010 by the United Department of Health and Human Services (DHHS).

The purpose of this report is to evaluate the RAC demonstration and to share with all interested parties information about the demonstration. Congress authorized the RAC demonstration for the purpose of identifying underpayments and overpayments and recouping overpayments under part A or B of the Medicare program.

UnitedHealthcare of Mississippi will emphasize wellness and health promotion programs as it assumes responsibility January 1, for the Children's Health Insurance Program (CHIP) administered by the Mississippi Division of Medicaid (DOM).

Approximately 67,000 children currently enrolled in the program will transfer to UnitedHealthcare Jan. 1. Enrollment is through DOM, which determines eligibility for the program based on annual family income and age.

Access to healthcare is perhaps one of the most basic human rights today and to secure that human right, the California government is establishing limits for how long HMO’s and their doctors can make patients wait for appointments.

What is the New Response Time

Sparked by the incessant numbers of patient complaints about long waiting period, Cindy Ehnes, director of the state Department of Managed Health Care, believes that the new regulation will improve the patient-physician relationship and will improve the quality of care.

Fraudulent discount health cards take advantage of vulnerable consumers and should face some of the toughest restrictions in the nation, a top state regulator said Monday.

The cards are advertised as providing discounts on health care bills. But too often, when consumers seek to use them, they find their doctors or pharmacies have never heard of the card, said Cindy Ehnes, director of the California Department of Managed Health Care.

At a news conference Monday in Oakland, Ehnes announced plans to license such companies and to impose other regulations to ensure they deliver on their promises.

In 2008, the number of nonelderly Americans without health insurance approached 47 million people, with millions of others concerned that a faltering economy may increase their chances of losing their own health care coverage. As the United States considers a variety of alternatives to decrease the ranks of the uninsured, Katherine Swartz offers a timely book on how the face of the uninsured has dramatically changed over the past quarter century and provides a thoughtful proposal for improving how health insurers can better address this crisis in coverage. In Reinsuring Health, Swartz examines whether a public–private health care reinsurance model can be implemented on a national level, designed as a program in which the federal government assumes the role of the reinsurer of catastrophically high health care risks.

A new fleet of ambulances are now transporting metro-east passengers in wheelchairs and on stretchers -- seniors, the disabled, special-needs children and others in non-emergency situations.

"We're kind of a step between a cab ride and an ambulance ride," said Steve McGoff, president of Metro East EMT.

McGoff and his father launched the venture last month in Collinsville, becoming the metro-east's franchise of the St. Louis-based Express Medical Transporters. The nonprofit business began in St. Louis in 1996. Founder Bernie Squitieri had been the general manager of one of the largest taxi cab companies in the Bronx when he moved to St. Louis 17 years ago to be closer to his wife's family. He established his own taxi service, Arnold Taxi, with just a 1989 Chevy Caprice in November 1995.

More employers are taking steps to improve their employees' health by making sure they take their medicines as prescribed, a move that could stave off more serious and costly health consequences, according to a new report sponsored by the National Pharmaceutical Council (NPC).

Medication compliance, sometimes referred to as medication adherence, is simply following a medicine treatment plan developed by an individual's health care provider, filling prescriptions, and taking medications as prescribed.

After months of legislative limbo on U.S. healthcare reform, health insurers such as Humana Inc and UnitedHealth Group Inc are bracing for more fallout from Washington over their Medicare plans.

The U.S. government body that oversees the Medicare program for the elderly is expected on Friday to release its preliminary decision on 2011 payment rates for privately run Medicare Advantage plans.

"The concept of access with evidence development (AED), also known as 'coverage with evidence development' in the Medicare programme, has long been discussed as a policy option for ensuring more appropriate use of new technologies in the US. This article provides a comprehensive overview of more than 10 years of US experience with AED, both in the public and private healthcare sectors," researchers in the United States report.

Sterling Heights, Mich., resident Solomon Nathaniel was sentenced today to 62 months in prison for his role in a wide-ranging conspiracy to defraud the Medicare program, announced Assistant Attorney General Lanny Breuer of the Criminal Division; U.S. Attorney for the Eastern District of Michigan Barbara L. McQuade; Special Agent in Charge Andrew G. Arena of the FBI's Detroit Field Office; and Special Agent in Charge Lamont Pugh III of the U.S. Department of Health and Human Services, Office of Inspector General's (HHS-OIG) Chicago Regional Office. U.S. District Judge Sean F. Cox also ordered Nathaniel to pay $2,875,000 in restitution and to serve a three-year term of supervised release following his incarceration.

The run-up to the U.S. health care overhaul instilled a lot of fear in a lot of people, if some of the incendiary comments from Republicans were any indication. But a day after the House of Representatives voted in favour of a $940-billion (U.S.) bill that amounts to one of the most sweeping changes in the country's health care in decades, the stock market reacted with a collective shrug.

Despite early jitters, the stock market didn't dive and health care stocks in particular weren't torpedoed. Within the S&P 500, health care equipment stocks rose, health care facilities stocks rose, health care distributors rose and pharmaceuticals rose. Managed health care stocks did fall, but by all of 1.1 per cent.

Our fundamental outlook for the managed health care sub-industry for the next 12 months is positive. The uncertainty surrounding the prospects of whether there will be health reform has ended. The health reform package, which included the Senate health reform bill, was passed in the House of Representatives on March 21 and signed into law by President Obama on March 23. As we went to press, the reconciliation bill, which revises the Senate bill, was awaiting Senate approval. We view the health reform package as positive for managed care organizations (MCOs), on balance.

Accreditation--The process by which an organization recognizes an institution as meeting predetermined standards

Actuarial Soundness-- The requirement that the development of capitation rates meet common actuarial principles and rules.

Adjusted Average Per Capita Cost (AAPCC)--The estimated average fee-for-service cost of Medicare benefits for an individual by county of residence. It is based on the following factors: age, sex, institutional status, Medicaid, disability, and end stage renal disease status. HCFA uses the AAPCCs as a basis for making monthly payments to TEFRA contractors

Along with so many other things, keeping a lid on spending seems to have gotten lost in the health care overhaul. Individuals lose some incentive to save a couple of bucks by having fewer tax-free dollars in their health savings accounts. A panel to oversee Medicare disbursements based on the cost of clinical effectiveness of treatments--zapped, thanks to intense lobbying by drug makers, doctors and every other medical interest group. That leaves medical providers and health plans, which have little motivation, unless the employers who buy insurance turn the screws.

They rarely do. But Edward Kaplan, a New York City health care consultant, last year came up with a simple way to save a pile of money for a Boston union representing supermarket workers: Its medical plan stopped covering Nexium, saving $133,000. The heartburn medicine is a $5 billion blockbuster for its manufacturer, AstraZeneca. At $2,000 for a year's supply, it was the union plan's second-most-prescribed pill, accounting for 5% of all drug costs. But its active molecule is almost identical to the one you get in cheap over-the-counter versions of Prilosec.

DST Health Solutions, LLC announced the release of Version 9.0 of The Johns Hopkins University's Adjusted Clinical Groups (ACG) System. ACG Version 9.0 includes extensive enhancements that not only improve predictive accuracy but also identify opportunities for intervention to improve health outcomes. DST Health Solutions is the exclusive distributor of the ACG System in the United States.

"Risk adjustment and predictive modeling are critical to measuring population health to support quality assessment and payment reform," said Professor Jonathan Weiner, co-developer of the original ACG System and leader of the research and development team at the Johns Hopkins Bloomberg School of Public Health. "The ACG System was conceived to ensure access and equity in healthcare purchasing. Version 9.0 will allow users to better understand the needs of the chronically ill."

The California Department of Managed Health Care issued the following press release:

Cindy Ehnes, Director of the Department of Managed Health Care (DMHC), has announced the appointment of Andrew George as Assistant Deputy Director of the Help Center, effective March 11, 2010.

"Andrew is a major asset to the DMHC, having worked as one of its consumer advocates for the past eight years, and will help further our goals to protect California health care consumers," said Ehnes. "He is recognized as a leader, mentor and effective problem solver and will be able to seamlessly continue the excellent work produced by all Help Center staff."

The management paradigm for multiple sclerosis (MS) continues to evolve and is shifting toward earlier diagnosis, differentiation of patients with varying clinical prognoses, and earlier initiation of treatment in selected individuals. Based on surveys conducted at the 2008 annual conference of the Academy of Managed Care Pharmacy (AMCP) and at regional meetings held in 2009, several topics were identified for which pharmacists indicated a need for new and updated information.