Hierarchical Condition Category (HCC) coding is a payment model implemented by CMS in 2003 to assign a Risk Adjustment Factor (RAF) to individuals with chronic illnesses based upon a combination of their health conditions and demographic circumstances. HCCs are split…
The Centers for Medicare & Medicaid Services (CMS) proposed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) in late April, 2016. This release announced a fundamental overhaul of physician payment methodologies from a model reimbursing each individual service…
As The Department of Justice (DOJ) recently filed Antitrust lawsuits against both the Connecticut-based Aetna and Indianapolis-based Anthem “Mega-Mergers,” the DOJ is suggests a February start date to the trial. With Aetna aiming to complete a $37 billion acquisition of Humana…
Developments continue regarding the proposed mergers between Anthem/Cigna and Aetna/Humana. Yesterday, the Justice Department reported they will likely file lawsuits this month to halt both proposed mergers. If the Justice Department does take action, it may significantly delay any merger. …
The Office of the National Coordinator for Health IT recently released defined interoperability measures as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These measures intend to clarify what exactly it means to, “achieve widespread exchange…
If the proposed Anthem/Cigna and Aetna/Humana mergers are allowed to proceed, the combined entities will control roughly 90 percent of both Georgia’s individual health insurance market. Additionally, these entities will subsequently control 90 percent of both the Medicare Title XVIII…
In an interesting turn for political support, there now exists a desire by a small number of Georgia Republicans that are now open to the idea of expanding Medicaid. However, they will face significant hurdles to do so. The conservative…
There continues to be developments regarding the proposed mergers between Anthem/Cigna and Aetna/Humana. Yesterday, the Justice Department reported will likely file lawsuits this month to halt both proposed mergers. If the Justice Department does take action, it may significantly delay…
The Merit-Based Incentive Payment System (MIPS) is the future value-based program for Medicare Part B Providers that should be considered the default Medicare payment program beginning January 1, 2019 with a two-year look-back, therefore truly beginning in 2017. This program…
As the healthcare industry continues to evolve, the Center for Medicare and Medicaid Services (CMS) has proposed five changes for the Patient Protection and Affordable Care Act. The proposed changes are focused on: Risk Adjustment, Network Adequacy, Out-of-Pocket Maximums, Standardized…