Medicare/ Medicaid

Beefing up its Medicaid managed care offerings, Aetna has acquired Phoenix, AZ-based Medicaid management firm Schaller Anderson for $535 million. Schaller Anderson serves more than 1.3 million beneficiaries and manages more than $3 billion in benefits. It has about 1,800 employees in nine states. The company was started by Joseph Anderson and Dr. Don Schaller, who founded the company more than 20 years ago after helping to create Arizona's Medicaid program. The buy follows a previous deal …

President Bush delivered a blessing for medical educational programs this week as part of new legislation. By signing the Iraq war spending bill, which contained language impacting Medicaid reimbursement, Bush also agreed to halt planned changes to federal Medicaid match funding. The Bush administration had previously proposed to eliminate Medicaid payments given directly to hospitals as a state match. Teaching hospitals have been using that money to pay for residency programs, but the …

Though it hasn't started yet, physicians are already questioning whether CMS's pay-for-performance program will work over the long term. Physician critics say that many practices won't have the time, resources or staff to begin quality reporting. To get the 1.5 percent bonus, physicians will be asked to report on 74 measures for claims between July 1st and December 31st. To make this happen, it's likely that the practices will have to upgrade their IT infrastructure, a step which can be …

Federal investigators are calling for the state of Missouri to pay back at least $8 million in Medicaid funding, arguing that the state's provider tax doesn't follow federal law. The state, which has been fighting with the feds since last year, imposes a tax on hospitals, nursing homes, pharmacies and healthcare management firms that generates about $1.1 billion per year. The state has leveraged that money to pull in $1.8 billion in Medicaid money from the federal government. The feds are …

Quite aware that a misstep could generate a huge backlash among hospitals, CMS has chosen a conservative course for its planned publication of cardiac death rates. Starting next month, the agency will publish death rates for heart attack and heart failure on its Hospital Compare website. The reports, which reflect stats from July 2005 to June 2006, profile heart attack and heart failure patients who died within a month of entering the …

Medicare has set plans to stop paying for 13 common conditions typically created by hospital errors, putting out a proposal that could be implemented late next year. Conditions cited include catheter-related urinary tract infections, bed sores, MRSA infections, wrong-site surgery and surgical site infections. Not only would such a policy have a potentially significant effect on hospitals, it could provoke the institution of similar policies by commercial health plans, which often follow …

A Medicare auditing firm part-owned by the husband of a U.S. Senator has come under intense scrutiny by the California state legislature, dogged by claims that it's rejecting claims unfairly just to make profits for itself. The company, PRG-Schultz International, is contracted with CMS to examine reimbursements and identify inappropriate payouts. PRG-Schultz gets 30 percent of any overcharges it finds. The California Hospital Association has said that PRG-Schultz is on a rampage, …

The current system Medicare used to gradually bump up reimbursement rates for physicians isn't fair, and should be replaced by one which takes physician practice costs into account, a group of 87 medical organizations told Congress. The group, which includes the American Medical Association, notes that hospitals and nursing homes are paid based on their costs. However, physicians are paid based on a formula known as the sustainable growth rate (SGR), tied to the U.S. economy, which has …

Hoping to fend off potential sanctions and additional regulations, health plans have unveiled a program designed to eliminate questionable Medicare enrollment marketing practices. The plans are responding to charges that independent sales reps, employed only during peak enrollment periods and often loosely trained, were not following the rules set forth by federal authorities. Seniors have complained that these reps show up without invitation and lie about plan details to force an …

A California company is quickly becoming one of the leaders in a new--and some say, critically important--care delivery niche. Care Level Management, of Woodland Hills, CA, cares for chronically ill patients in their homes rather than making them come to a physician's office. The idea is to head off potentially serious and expensive complications which would otherwise put them in the hospital. Care Level's primary client is CMS, which is paying Care Level a monthly case stipend and fee …