Insurance

HHS has announced goals and a timeline to move Medicare toward a quality-based payment system and away from the current fee-for-service payments.

A federal lawsuit accuses the Cleveland Clinic Health System of performing more tests and procedures on patients than necessary in order to obtain more Medicare payouts.

Medicare is giving bonuses to a majority of hospitals that it graded on quality, but many of those rewards will be wiped out by penalties the government has issued for other shortcomings, federal data show.

The new Republican chairman of the Senate Finance Committee says the GOP will chip away at Obamacare "piece by piece." Still, he says he will work with Democrats to continue funding for the Children's Health Insurance Program and overhauling Medicare pay for doctors.

Obama administration officials have warned that ambitious experiments run by the health law's $10 billion innovation lab wouldn't always be successful. Now there is evidence their caution was well placed.

Medicare payments for hospice care carried out in an assisted living facility more than doubled from 2007 to 2012, raising questions about the incentives that Medicare provides for hospice care.

The aging US population means that Medicare is taking care of more older, sicker people for longer periods of time. Population trends suggest this phenomenon will only increase, unless drastic management and healthcare delivery solutions are found.

The combination of 2 Medi-Cal primary care rate decreases could mean primary care providers who see a lot of Medi-Cal patients will have to scale back or stop seeing those beneficiaries.

Although infection prevention programs require ongoing investments, the money spent is worthwhile considering the costs saved as healthcare-associated infection rates fall, according to a study in the American Journal of Infection Control.

The 4 private companies that run Medicare's recovery audit program will have their contracts extended through 2015. But it's unclear what types of medical reviews or claims are going to be eligible for auditing.

Of the many benefits that come from achieving a 4-star CMS rating or better, retention and growth are probably the biggest ones, according to Snezana Mahon, PharmD, senior director Medicare solutions at Express Scripts.

With 2014 coming to a close, The American Journal of Managed Care is taking a look back at the most popular articles from this year. These most-read articles highlight the healthcare issues most important to providers, insurers, and policy makers.

The main barrier to widespread use of telehealth isn't technology or consumer acceptance; it's figuring out how to pay for it. Authors writing for The American Journal of Managed Care and The American Journal of Accountable Care discuss why today's payment models for accountable care organizations are a better fit for telehealth, and why regulatory changes make sense.

Gilead Sciences' hepatitis C drugs Sovaldi and Harvoni are the poster children for out-of-control drug costs, but competition from AbbVie's drug may place downward pressure on these prices.

CMS audits have found that some health insurance plans are struggling with the same issues year after year, which is concerning, said Sarah J. Lorance, vice president of Medicare compliance at Anthem.

San Diego County is doing much better than the national average at reducing readmissions to hospitals, yet nearly all their eligible hospitals are being penalized by Medicare's hospital readmissions penalty program.

Researchers at Stanford University found that when CMS stopped paying for 2 preventable, hospital-acquired conditions in particular, the incidence of the conditions dropped 35% in the Medicare population.

Anthem, Inc, increased its managed care footprint in the state of Florida. On Monday, the company has entered into an agreement to acquire Simply Healthcare Holdings, Inc.

CMS' Sean Cavanaugh announces in a blog post that 89 newcomers will participate in 2015. But ACOs remain a work in progress, with rule changes on the way and some discussion about whether these entities are assuming enough risk or dampening competition in certain markets.

Accountable care organizations (ACOs) are still a new creature in the world of managed care, and not all are alike. As the authors of a new comparative analysis in The American Journal of Managed Care outline, Medicare contracts dominate the ACO landscape, with only half of these entities having a contract with a private payer.

More than 700 hospitals will be penalized in fiscal year 2015 as a result of poor scores in CMS' Hospital-Acquired Condition (HAC) Reduction Program.

In the next several weeks more than 257,000 physicians and other healthcare providers will receive notification that 1% of their pay next year will be penalized for failing to meet meaningful use, CMS announced Wednesday.

States designing and testing healthcare payment and service delivery models to improve quality of care and lower costs will be receiving more than $665 million in funding from the government, according to HHS Secretary Sylvia M. Burwell.

Substituting telehealth services for in-person visits can generate savings of roughly $126 per commercial telehealth visit, according to a new actuarial study from the Alliance for Connected Care.

The authors find 51% of accountable care organizations have private payer contracts, which are more likely than public contracts to include downside risk and upfront payments.

The rule being published tomorrow not only grants same-sex spouses the right to act as medical decision-makers, but it also requires Medicare and Medicaid providers to inform patients of these rights.

The Sunshine State seeks to hold down costs with managed care for its Medicaid population and seniors, but it's meeting resistance.

Rules issued today will help CMS keep fraudulent providers and suppliers away from Medicare, following a series of crackdowns in "hot spots" around the country.

The 3-year pilot is expected to reel-in significant cost savings for Medicare, which has seen a lot of fraudulent charges with services and equipment.