Long-term Benefits Outweighs Risks of Running an SBM, Report Finds

A growing number of reports have showed it is in states’ interests to run their own health insurance marketplace.  

Most recently, a report from the Urban Institute and the Georgetown Center on Health Insurance Reforms uncovered the primary factors driving states to switch from the HealthCare.gov platform to a full state-based marketplace (SBM). The authors of the report spoke with 22 stakeholders from Nevada, New Jersey, New Mexico, Oregon and Pennsylvania—all states transitioning to an SBM model—to gather evidence 

(more…)

Continue Reading

What You Need to Know: Proposed Reforms to the Federal Anti-Kickback Statute and the Stark Law

Last week, the Department of Health and Human Services (HHS) published two proposed rules: “Modernizing and Clarifying the Physician Self-Referral Regulations” and “Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements.” This piece provides a recap of the main points and motivations in each rule.

(more…)

Continue Reading

Waste Accounts for 25% of Health Care Spending. Addressing Fraud and Abuse Can Help.

It already hurts to hear that the United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product and more than $10,000 per individual.

A report published last week in The Journal of the American Medical Association makes those numbers even more painful as it reveals the estimated cost of waste in the United States ranges from $760 billion to $935 billion, accounting for approximately 25% of total health care spending. This amount exceeds national military spending, as well as total primary and secondary education spending.

(more…)

Continue Reading

Don’t Leave Money on the Table: Five Steps to Addressing SDOH

PricewaterhouseCoopers Health Research Institute recently released their new report: “Action Required: The Urgency of Addressing Social Determinants of Health.” Anyone in health care eager to save on costs and create efficient medical interventions should review this report. This piece provides a review of report, highlighting the five steps PwC recommends taking to lead in social determinants of health (SDOH).

(more…)

Continue Reading

Rising Uninsured Rate and How States Can Respond

Earlier this month, many noted the Census Bureau’s report of the increasing number of uninsured Americans. 8.5 percent, about 27.5 million people, lacked health insurance in 2018, up from 7.9 percent in 2017. It was the first year-to-year increase in the uninsured rate since the Affordable Care Act (ACA) in 2010.

(more…)

Continue Reading

CMS Continues Mission on Integrity with Affiliations Final Rule

Last week, the owner and CEO of Video Doctor Network pled guilty to a $424 million Medicare kickback scheme. He admitted to receiving kickbacks and bribes from recruiters, pharmacies and brace suppliers in turn for arranging doctors to order medically unnecessary orthotic braces for Medicare beneficiaries. As reported by Healthcare Dive, this is one of the largest schemes to defraud Medicare ever investigated by the Federal Bureau of Investigation (FBI) and the Health and Human Services (HHS) Office of the Inspector General and prosecuted by the Department of Justice.

(more…)

Continue Reading

Product Talk: Enhanced Direct Enrollment

Softheon’s private-label enrollment solution, Enhanced Direct Enrollment-as-a-Service (EDE) offers a unified enrollment experience and an updated, easy-to-use portal for Marketplace members. Now available to any health plan engaged in the ACA Marketplace once it informs CMS that it is partnering with Softheon as an EDE vendor, Softheon EDE uses a series of Centers for Medicare and Medicaid Services-based (CMS) application program interfaces (APIs) to process eligibility and changes behind the scenes. In this interview, we spoke with Min Kyu Han, one of EDE’s product owners. 

(more…)

Continue Reading
Close Menu