Appeals, Observation care

Medicare May Be Overpaying Hospitals For Patients Who Don’t Stay Long

By Susan Jaffe | Kaiser Health News in collaboration with National Public Radio | May 21, 2014, 9:35 a.m.

The federal government may be paying hospitals $5 billion too much as a result of an 18-month moratorium on enforcement of Medicare rules that tell hospitals when patients should be admitted, an independent Medicare auditing company told a congressional panel yesterday. The controversial rules were intended to reduce the increasing number of seniors hospitalized for observation but not admitted. If they have not been admitted to the hospital for at least three consecutive days, they are not eligible for follow-up nursing home coverage and may have higher out-of-pocket expenses while in the hospital. Medicare pays hospitals more for admitted patients than observation patients. MORE from NPR and Kaiser Health News

Affordable Care Act, The Lancet

Challenges loom for US health law as new insurance begins

lancet cover 2

Volume 383, Issue 9928, 3 May 2014

 

WORLD REPORT Millions of Americans met the mid-April extended deadline to enrol in coverage under the Affordable Care Act; now the real test of the law begins. Susan Jaffe reports from Washington, DC.

Just a few days after April’s extended enrolment deadline, President Barack Obama announced that some 8 million Americans had signed up for health insurance under his health-care law, exceeding the predictions dampened by a rocky rollout 6 months ago that prompted jokes on late-night talk shows, fuelled the opposition, and ultimately led to the resignation of his Health and Human Services secretary, Kathleen Sebelius, the nation’s top health official.

“The repeal debate is and should be over”, Obama proclaimed, referring to the 54 times Republicans in the US House of Representatives have voted to repeal or modify the law. “The Affordable Care Act [ACA] is working.”

But even the programme’s supporters say the next few months will be crucial to its success. [MORE] [PDF]

Long term care, Medicare costs

Medicare Seeks To Stop Overpayments For Hospice Patients’ Drugs

By Susan Jaffe  May 1,2014  KAISER HEALTH NEWS  in collaboration with wapo

New Medicare guidance taking effect today aims to stop the federal government from paying millions of dollars to hospice organizations and drug insurance plans for the same prescriptions for seniors. But the changes may make it more difficult for dying patients to get some medications, senior advocates and hospice providers say.

The new measures direct insurers not to pay for any prescriptions for hospice patients until they receive confirmation that the drugs are not covered instead by the hospice provider. Requiring additional authorization for these prescriptions will “prevent duplicate payments for drugs covered under the hospice benefit,” Medicare officials told hospice providers and insurers in a conference call three weeks ago. [More from KHN] [More from Washington Post]

Medicare Advantage

Feds Issue Rules To Protect Seniors Enrolled In Medicare Advantage Plans

By Susan Jaffe   |   April 8, 2014, 5:46 pm 
Connecticut Health Investigative Team and The Hartford Courant

UnitedHealthcare’s decision last fall to drop thousands of doctors from its Medicare Advantage plans in Connecticut and across the country has spurred Medicare officials to improve protections for seniors who lose their doctors.The new measures were announced late Monday along with a slight increase in next year’s payment rates to Medicare Advantage insurers who provide policies as an alternative to the traditional government-run Medicare program.

Nearly 16 million older Americans have enrolled in a Medicare Advantage plan, including more than 147,000 in Connecticut, which requires members to get treatment only from a network of health care providers. They cannot change plans during the year if their doctor leaves their network….

“I doubt that CMS would have given this as much attention without patients, providers and advocates demonstrating how deep and broad the effect was and how much pain and anguish it caused,” said U.S. Sen. Richard Blumenthal. CONTINUED in Connecticut Health Investigative Team CONTINUED in The Courant

Long term care, Medicare costs, Physical therapy

A Quiet ‘Sea Change’ in Medicare

By Susan Jaffe   |   March 25, 2014, 5:00  am    

Ever since Cindy Hasz opened her geriatric care management business in San Diego 13 years ago, she has been fighting a losing battle for clients unable to get Medicare coverage for physical therapy because they “plateaued” and were not  were not getting better.

“It has been standard operating procedure that patients will be discontinued from therapy services because they are not improving,” she said.

Glenda Jimmo at home in Lincoln, Vt., in 2012. (Paul O. Boisvert for The New York Times)

No more. In January, Medicare officials updated the agency’s policy manual — the rule book for everything Medicare does — to erase any notion that improvement is necessary to receive coverage for skilled care. That means Medicare now will pay for physical therapy, nursing care and other services for beneficiaries with chronic diseases like multiple sclerosis, Parkinson’s or Alzheimer’s disease in order to maintain their condition and prevent deterioration.

Articles most frequently emailed by NYTimes.com readers March 25, 2014 (click to enlarge)

But don’t look for an announcement about the changes in the mail, or even a prominent notice on the Medicare website. Medicare officials were required to inform health care providers, bill processors, auditors, Medicare Advantage plans, the 800-MEDICARE information line and appeals judges — but not beneficiaries. MORE

Medicare Advantage, Medicare costs

Draft Rules Would Help Protect Seniors When Medicare Advantage Plans Drop Doctors

By Susan Jaffe  March 24, 2014  KAISER HEALTH NEWS  in collaboration with wapo

Federal officials are considering new Medicare Advantage rules to help protect seniors when insurers make significant reductions to their networks of doctors and other health care providers. The proposals follow UnitedHealthcare’s decision to drop thousands of doctors from its Medicare Advantage plans in at least 10 states last fall.

The government’s response is part of the 148-page announcement of proposed rules and payment rates for next year’s Medicare Advantage plans released last month by the U.S. Centers for Medicare & Medicaid Services. Officials say that the terminations only a few weeks before Medicare’s Dec. 7 enrollment deadline may not have given seniors enough time to find new doctors, choose a different plan or rejoin traditional Medicare, which does not restrict beneficiaries to a limited network of providers.

…Although the announcement does not name any insurance companies, officials prefaced the proposals by writing, “Recent significant mid-year changes to MAOs’ [Medicare Advantage organizations’] provider networks have prompted CMS to reexamine its current guidance on these requirements and to consider augmenting such guidance in response to such changes.” [More from KHN] [More from Washington Post]

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By Susan Jaffe | March 7, 2014 | Kaiser Health News in collaboration with wapo
Federal efforts to strengthen inspections of the nation’s nursing homes are gaining momentum after a government probe uncovered instances of substandard care.
The March 3 report by the HHS Inspector General found that an estimated one-third of residents suffered harm because of substandard care and that the chances of nursing home inspectors discovering these “adverse events” are “slim to none,” said Ruth Ann Dorrill, a deputy regional director for the inspector general and the manager of the investigation.
Nearly 60 percent of these incidents were preventable — including injuries due to falls or medication errors — and more than half of residents were hospitalized as a result, costing Medicare an estimated $2.8 billion in 2011, according to investigators. In 6 percent of the cases, poor care contributed to residents’ deaths….
After reviewing a September draft of the IG report, Medicare officials became interested in using the IG’s investigative techniques, methods not normally used in measuring nursing home quality, Dorrill said. [More from KHN] [More from Washington Post]

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By Susan Jaffe  | February 28, 2014 |  Kaiser Health News produced in collaboration with 

It used to be difficult for Edith Couturier, an 85-year-old resident of the District of Columbia, to explain to her adult children on the West Coast all the details of her medical appointments. But now she doesn’t go alone — she takes along a volunteer “medical note taker.”

“There are four ears listening to what the doctor says,” said Couturier. That second set of ears belongs to Sharon Wolozin, who takes notes the old-fashioned way – with pen and paper – and then reads some of the main points aloud to confirm them with the doctor.

Wolozin is a volunteer for the Northwest Neighbors Village in Washington, D.C., one of the more than 200 “villages” across the United States. These neighborhood membership organizations provide volunteers and other resources to help with everything from transportation and snow shoveling to hanging curtains and solving computer glitches.

But as many of the Northwest Neighbors’ 210 dues-paying members “age in place” – the village movement’s top goal — some need more than just a ride to the doctor, said executive director Marianna Blagburn.
[More in KHN] [More in USA Today]

Appeals, CMS, HHS, Medicare costs, Observation care

As HHS Moves To End Overload Of Medicare Claims Appeals, Beneficiaries Will Get Top Priority

By Susan Jaffe  Jan. 21, 2014  KAISER HEALTH NEWS  in collaboration with 

Medicare beneficiaries who have been waiting months and even years for a hearing on their appeals for coverage may soon get a break as their cases take top priority in an effort to remedy a massive backlog.

Nancy Griswold, the chief judge of the Office of Medicare Hearings and Appeals (OMHA), announced in a memo sent last month to more than 900 appellants and health care associations that her office has a backlog of nearly 357,000 claims. In response, she said the agency has suspended acting on new requests for hearings filed by hospitals, doctors, nursing homes and other health care providers, which make up nearly 90 percent of the cases. But beneficiaries’ appeals will continue to be processed.

“We have elderly or disabled Medicare clients waiting as long as two years for a hearing and nine months for a decision,” said Judith Stein, executive director of the Center for Medicare Advocacy. [More from KHN] [More from Washington Post]

Affordable Care Act, The Lancet

The Affordable Care Act’s insurance programme takes effect

lancet cover 2

Volume 383, Issue 9912,  11 January 2014

 

WORLD REPORT Coverage kicked in for millions of Americans on Jan 1 under the Affordable Care Act while officials urged others to enrol before the 2014 sign-up deadline.Susan Jaffe reports from Washington, DC.

The Obama Administration faces what might be its most daunting challenge under the law: making sure an untested programme functions—will newly insured patients be able to get medical treatment or fill prescriptions?—while continuing to encourage people to sign up before the March 31 deadline for 2014 coverage, guaranteeing that the upgraded online sign up system keeps pace with demand, and fighting the latest lawsuit and political attack as the 2014 mid-term election campaign heats up. [MORE] [PDF]

Appeals, CMS, HHS, Long term care

Fighting ‘Observation’ Status

By Susan Jaffe   |   January 10, 2014, 2:41 pm  

Every year, thousands of Medicare patients who spend time in the hospital for observation but are not officially admitted find they are not eligible for nursing home coverage after discharge. 

…Medicare officials have urged hospital patients to find out if they’ve been admitted. But suppose the answer is no. Then what do you do?

Medicare doesn’t require hospitals to tell patients if they are merely being observed, which is supposed to last no more than 48 hours to help the doctor decide if someone is sick enough to be admitted. (Starting on Jan. 19, however, New York State will require hospitals to provide oral and written notification to patients within 24 hours of putting them on observation status. Penalties range as much as $5,000 per violation.)  [Continued in The New York Times.]

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Judge’s Medicare Advantage Order Could Have National Impact

By Susan Jaffe | December 6, 2013 | Kaiser Health News produced in collaboration with  

In a decision that could have national implications, a federal judge in Connecticut temporarily blocked UnitedHealthcare late Thursday from dropping an estimated 2,200 physicians from its Medicare Advantage plan in that state. While the judge’s decision affects only the physicians in Fairfield and Hartford Counties who brought suit, several other medical groups are considering filing similar actions.

“This is very good news from Connecticut,” said Dr. Sam L. Unterricht, president of the Medical Society of the State of New York. “We will definitely seriously consider filing a suit in New York as well.” [Continued in Kaiser Health News and USA Today]

Link

By Susan Jaffe  | November 29, 2013 |  Kaiser Health News produced in collaboration with 

Dorathy Senay’s doctor had some bad news after her last checkup, but it wasn’t about her serious blood disorder called amyloidosis. Her Medicare Advantage managed care plan from UnitedHealthcare/AARP is terminating the doctor’s contract Feb. 1. She is also losing her oncologist at the prestigious Yale Medical Group — the entire 1,200 physician practice was axed. Senay, 71, of Canterbury, Conn., is among thousands of UnitedHealthcare Medicare members in 10 states whose doctors will be cut from their plan network.

The company is the largest Medicare Advantage insurer in the country, with nearly 3 million members. More than 14 million older or disabled Americans are enrolled in Medicare Advantage plans, an alternative to traditional Medicare that offers medical and usually drug coverage but members have to use the plan’s network of providers.

“I have a rare incurable disease and these doctors have saved my life,” said Senay. “I am in good hands and I will not change doctors.”

…Medicare officials review the private plans every year to make sure they comply with network adequacy and other requirements, but the agency did not approve the reconfigured networks resulting from the new provider cancelations. Spokesman Raymond Thorn said the agency “is currently reviewing UHC and other plans’ provider networks and closely monitoring all areas that have experienced disruptions to ensure that beneficiaries have full, transparent and timely information and access to needed care.” [More from KHN] [More in USA Today]

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By Susan Jaffe   |   November 1, 2013, 11:57 am 

Older adults and their caregivers have complained for years that Medicare, which now covers 52 million Americans, does not provide dental benefits.
For some adults with Medicare, the online insurance exchanges created by the Affordable Care Act may offer an alternative. MORE

Dental Coverage on the Insurance Exchanges