Compli by Osato

#questionforgroup: How can monopolistic practices improve Americans' #accesstocare ( this is a realquestion - emphasis on affordability and high quality)? Private equity-backed physician roll-ups and joint ventures in healthcare transactions have always drawn scrutiny from state and federal regulators. The Federal Trade Commission, U.S. Department of Justice, and U.S. Department of Health and Human Services (HHS) have joined forces to make it easier for individuals to report suspicions of unfair and anticompetitive practices via a new online portal called HealthyCompetition.gov. Fair competition in healthcare forces lower prices and better quality, which includes receiving fair and just wages for healthcare service providers. This joint initiative between FTC, DOJ, and HHS will provide a crucial channel for the agencies to hear from the public, bolstering their work to check illegal business practices that harm individuals- including Medicare and Medicaid beneficiaries. Complaints submitted via the website must be specific to healthcare competition. The federal agencies will not consider complaints about failure to pay claims, questions about coverage, insurance rates, billing disputes, or general unhappiness about the healthcare system. Complaints may be anonymous, or those seeking action can include contact information. Happy reporting! #monopolisticpractices #healthcare #competition #report #faircompetition #FTC #DOJ #HHS #HealthyCompetition #Medicare #Medicaid #affordability #quality #physicianrollups #jointventures #regulators

#Data in #healthcare is everything. In the administration of a #medicareadvantage plan, payers collect a great deal of required data - however, we should always be asking, "Is this data useful"? In Centers for Medicare & Medicaid Services #CMS latest effort to increase transparency in #medicareadvantage, it has clarified and expanded reporting requirements regarding supplemental benefits. This is in addition to #CMS requiring #medicareadvantage #insurers to post summary data on the timeliness and use of #priorauthorization on their websites beginning in 2026. According to a KFF report, there are certain questions that will remain unanswered - even with these additional asks, thus hindering the ability for #policymakers and researchers to determine the efficacy of these regulatory changes. For example, #payors are not required to report #priorauthorization requests, denials, and appeals by type of service, for specific plans within a contract, or reasons for prior authorization denials. Additionally, payors are also not required to report to #CMS complete information on denied claims for #inpatient, #physician and other services already delivered to enrollees. While there is other information collected by CMS, but not published, including #OOP spending by enrollees, and the characteristics of enrollees who switch or disenroll to get coverage under original #medicare, this information would also be useful to #medicare beneficiaries when choosing among the large number of plans offered in their area. These are reasonable requests that all #payers should have already been reporting out on. However, the fact that there are still gaps in reporting requirements highlights the need for continued efforts to improve transparency and the production of useful information. Well that certainly is novel - the production of useful information.💡🤔 Read more about the KFF report here: https://lnkd.in/ewb8fRjf

Time to step up #oversight efforts, to ensure states compliance with MH/SUD parity requirements. In the latest episode of "When the regulator needs regulating" - U.S. Department of Health and Human Services (HHS) #oig Found Centers for Medicare & Medicaid Services #cms did not ensure that selected States complied with Medicaid managed care #mentalhealth and#substanceusedisorder MH/SUD parity requirements. For all eight States reviewed, State contracts with #medicaid MCOs did not: 🤷🏾♀️Contain required parity provisions by the compliance date 🤷🏾♀️Conduct required parity analyses (five States), 🤷🏾♀️Make documentation of compliance available to the public by the compliance date (eight States). Moreover, all eight States may not have ensured that all services were delivered to MCO enrollees in compliance with MH/SUD parity requirements. Specifically: 🤷🏾♀️MCOs applied financial requirements (two States); and 🤷🏾♀️quantitative treatment limitations (six States) for MH/SUD services that were more restrictive than those for medical/surgical services in the same classifications Additionally, States also imposed nonquantitative #treatment limitations (eight States) on MH/SUD benefits that were not comparable to, or were more stringent than, those for #medical #surgical benefits in the same classifications.

This proposed transaction should give us all pause. Beleagured Steward Health Care has recently disclosed  it wants to sell its network of #physicians to UnitedHealth Group Health Group, a move that could help Steward pay some of its bills, including a reported $50 million in unpaid rent. It's also trying to sell its nine #massachusetts #hospitals . Optum, a UnitedHealth Group subsidiary, is already THE LARGEST EMPLOYER OF PHYSICIANS IN THE COUNTRY, controlling over 10 percent of American doctors, which means this deal raises significant #antitrust concerns, not only in #massachusetts , but across the US. Senator Elizabeth Warren , what's next? https://lnkd.in/eQ9S6fbY

Starting on January 1, Centers for Medicare & Medicaid Services #cms has allowed payment under Medicare Part B for reimbursement for services furnished by Marriage and Family Therapists #lmft & Mental Health Counselors. Given that these clinicians are new to #medicare, CMS has provided updated Enrollment Guidance in recently issued FAQs. With these FAQs CMS clarified: 👩🏾⚕️Supervision requirements; see questions 2–3 👩🏾⚕️Mental health professionals who can enroll as MHCs; see question 13 👩🏾⚕️Reassignment arrangements; see question 25 👩🏾⚕️ #telehealth enrollment process; see question 34  👩🏾⚕️Opt-out requirements; see questions 40–42 👩🏾⚕️Additional resources; see question 4. Additional questions about enrollment guidance? Send your question to osato@complibyosato.com

Another item for both #payer and #providers #complianceofficers to monitor - patient remote monitoring and the #medicare reimbursements associated with them. Some of these first tier, downstream, and related entities #fdr are signing up #medicare enrollees for this service, regardless of medical necessity and bill Medicare even when no monitoring occurs. #payers be forewarned, these #fdr should be part of your "high-risk" vendor list, and routinely monitored to ensure compliance with #medicareadvantage requirements. Remote monitoring services billed to Medicare grew from fewer than 134,000 to 2.4 million in 2021, according to federal records analyzed by KFF Health News. In 2019, Medicare made it easier for #doctors to bill for monitoring routine vital signs such as #bloodpressure , weight, and blood sugar. Previously, Medicare coverage for remote monitoring was limited to certain patients, such as those with a #pacemaker . Clinicians can get reimbursed by #medicare even when the monitoring is done by clinical staff in a location that differs from the physician - an allowance lobbied for by #telemedicine companies. Part of the allure is that Medicare will pay for remote monitoring indefinitely regardless of patients’ health conditions as long as their doctors believe it will help. For doctors with 2,000 to 3,000 patients, the money can add up quickly, with Medicare paying an average of about $100 a month per patient for the monitoring, plus more for setting up the device. Additionally, with the fed allowing insurers to waive patient cost sharing during the pandemic, the patient acquisition by marketing no co-pays would be enticing. HHS Office of Inspector General is currently conducting investigations after a surge in complaints about some remote patient monitoring companies.

#compliance #3rdparty #vendors and #procurement teams, have you dusted off your First Tier, Down Stream, and Related Entity ( #fdr ) #oversight plans yet? Healthcare Navigation company, Quantum Health ' s , recent Medicare Advantage offering, requires that you do. Quantum Health has traditionally served #selfinsured employers and helps connect employees with #providers and digital health solutions. With it's new #medicareadvantage offering, Quantum Health will be delegated services that include conducting annual health risk assessments, connecting members with a #primarycarephysician and clinical and customer support services related to benefits and claims. All things that certainly make Quantum Health a "high-risk" vendor - subject to a heightened level of scrutiny and oversight, given this vendors impact on #accesstocare and #starratings . Quantum Health’s launch into the MA market comes at a time when MA enrollment is on the rise. More than half, or 51%, of eligible #medicare beneficiaries are enrolled in a Medicare Advantage plan, according to KFF. There is increased scrutiny placed on #medicareadvantage plans when utilizing vendors new to the Medicare Advantage space. Thus, it behooves #Payors to ensure that their audit plan and risk assessments include reviews of all vendors that have the capacity to put the organization at #risk of an #enforcement action (and that's all of them!).

This recently unsealed #whistleblower case should have #primarycare providers on edge, and #complianceofficer dusting off their #thirdparty vendor oversight and #fdr #audit work plans! The case alleges that Aledade, Inc. , a #physician led #aco that oversees the nation’s largest independent network of primary care medical practices, cheated #medicare out of millions of dollars using billing software “rigged” to make patients appear sicker than they were (there is a legit reason why #riskadjustment Data Validation audits exits! ). Based in Bethesda, #maryland , Aledade, Inc. helps manage independent primary care clinics and medical offices in more than 40 states, serving some 2 million people. The civil suit alleges that Aledade, Inc. Inc.’s billing apps and other software and guidance provided to doctors improperly boosted revenues by adding overstated medical diagnoses to patients’ #electronicmedicalrecords to make patients appear sicker than they were. For example, the suit alleges that Aledade, Inc. “conflated” #anxiety into #depression , which could boost payments by $3,300 a year per patient (there is a legit reason why #reimbursement related to #behavioralhealth are placed under high scrutiny!). Other allegations include Aledade, Inc. decided that patients over 65 years old who said they had more than one drink per day had #substanceuse issues, which could bring in $3,680 extra per patient. The lawsuit also names as #defendants 19 independent #physician practices, many in small cities in #delaware , #kansas , #louisiana , #northcarolina , #pennsylvania , and #westvirginia . According to the suit, the doctors knowingly (not a word that bodes well for you in the world of #fraud #waste and #abuse) used Aledade, Inc. software to trigger illegal billings, a practice known in the medical industry as "upcoding." The whistleblower case, filed in #federalcourt in #seattle in 2021 but remained under seal until January of this year. The whistleblower, a former “senior medical director of risk and wellness product” at Aledade, Inc. from January 2021 through May 2021, alleges the company fired him after he objected to its “fraudulent course of conduct,” according to the suit. As always, this healthcare regulatory compliance legal eagle 🦅 will watching with her popcorn 🍿🍿🍿of course. https://lnkd.in/dnsNihjF

AstraZeneca 💊💊has lost its lawsuit 👨🏾⚖️ challenging #medicare drug price negotiation program after U.S. District Court for the District of Delaware concluded the #pharmaceutical giant has no standing to contest the law that created it, nor does the company have a constitutionally 📜 protected property interest in the matter. AstraZeneca’s lawsuit is one of eight filed by pharmaceutical companies that are challenging the #inflationreductionact (IRA) . AstraZeneca claimed that the IRA causes harm by disincentivizing innovation and violates its #constitutional rights to #dueprocess . Two suits from industry groups have also been filed - with one dismissed last month due to improper venue in the U.S. District Court, Western District of Texas . AstraZeneca drug Farxiga , a blockbuster AstraZeneca medicine with approvals in #type2diabetes #heartfailure , and #chronickidneydisease , is one of the first 10 drugs selected by #cms Centers for Medicare & Medicaid Services for negotiation. These drugs, which have no generic competition, represented more than $50 billion 💸💸💸 (billion!!) in Medicare Part D costs between June 1, 2022, and May 31, 2023. The court held, the harm AstraZeneca claims due to the law is hypothetical and could happen if the company were to develop new formulations of new uses of Farxiga’s active pharmaceutical ingredient—but only if these new uses received #fda approval, and then only if the drug were selected for price negotiation. Moreover, the Court disagreed with AstraZeneca’s claim that the law violates its rights under the 5th #amendment , which states that no one shall be “deprived of life, liberty, or property without due process of law.” As per the court, no one is entitled to sell to the government at prices the #government won't pay. Welp, AstraZeneca , I guess the court told you. Whose up next💊💊?

It is critical that the #federalgovernment and #payers find ways to improve the value of #medicare coverage, including making care more accessible and affordable. #compliance teams can help ensure that the program meets the needs of all beneficiaries, irrespective of their coverage choices. Ongoing internal #monitoring and #auditing, using an operationalized compliance framework, is integral in resolving issues related to #priorauthorization, a persistent issue for #medicareadvantage beneficiaries, and a crucial area of focus for #healthplans and their #compliance teams to ensure that #payers are operating within #cms requirements regarding medical service determinations. In this survey, conducted between Nov. 6, 2023, and Jan. 4, 2024 by the The Commonwealth Fund of 3,280 #medicare beneficiaries - about 1 in 3 #beneficiaries were somewhat satisfied with traditional Medicare and MA plans, however, lack of coverage, high prices and uncertainty over what was covered contributed to their satisfaction rating. A total of 22% of those using MA said they experienced delays in care because of prior authorizations. That compares to 13% of traditional Medicare beneficiaries. Of those with MA, 36% said they had to wait more than one month🩺 to see a doctor, compared to 34% with traditional Medicare! That is a long time to see a provider. Of the respondents, 10% on MA said the doctor or hospital they wanted to use wouldn’t accept their coverage; the same was true for 8% of people who used traditional Medicare. About 62% of people using MA plans had to have a health assessment to receive care, compared to 27% on traditional Medicare. The assessments spurred discussions with doctors, but it rarely led to changes in their care plans or helped them gain access to more services or benefits, participants reported. This finding is particularly troubling given #sdoh and the incredibly vulnerable populations in #snp plans coupled with the massive reimbursements associated with #snp . Overall, one-third of beneficiaries indicated their coverage fell short of their expectations. This raises questions about both Medicare Advantage plans and traditional Medicare and its impact on health outcomes. #accesstocare #sdoh https://lnkd.in/eAPhR3W6