The Texas Medical Association (TMA) and Blue Cross Blue Shield of Texas are launching a new services company, TMA PracticeEdge, to facilitate bringing the benefits of value-based reimbursements to the state’s independent physicians.

Independent practitioners face challenges to participating in (and benefitting from) alternatives to fee-for-service payment, such as having the funds necessary to invest upfront in resources for improved care management. TMA PracticeEdge aims to help providers address the barriers. The company, for example, will offer consultations on basic practice management and administrative simplification, assistance with the implementation of health information technology infrastructure, and experience with risk-based contracts. Additional services will be available for practices interested in creating care teams or developing an Accountable Care Organization.

Continue Reading New Venture Seeks to Support Independent Physicians in Texas

The Office of Inspector General for the Department of Health and Human Services (OIG) recently defended its practices pertaining to hospital compliance reviews in a published response to a letter from the American Hospital Association (AHA), while simultaneously announcing a voluntary suspension of reviews of inpatient short stay claims after October 1, 2013.[1]
Continue Reading Medicare Hospital Compliance Reviews are Legal and Sound, According to OIG

In mid-December, President Obama signed into law a $1.1 trillion spending bill known as the “Consolidated and Further Continuing Appropriations Act, 2015” or “Cromnibus.”[1] This post explores provisions that relate to the health sector and Affordable Care Act (ACA) implementation.
Continue Reading Effects of the New Federal Spending Package on the Health Sector

Network adequacy—a health plan’s ability to provide timely access to a sufficient number in-network providers—has become a matter of increased scrutiny during these early years of ACA implementation; Many consumer and physician advocacy groups have expressed concerns over the sufficiency of federal and state standards and oversight. In response, the National Association of Insurance Commissioners (NAIC) is in the process of updating its Network Adequacy Model Act, a draft of which was circulated earlier this month.[1]
Continue Reading The National Association of Insurance Commissioners Weigh in on Issues of Network Adequacy

Are changes to the landscape of physician hospital ownership ahead?

The Affordable Care Act amended the federal Stark Law to eliminate the “whole hospital exception” that permitted self-referrals provided the referring physician was authorized to practice at the hospital and the ownership or investment interest was in the hospital itself (as opposed to a subdivision). An exception, albeit a limited one, was created for existing hospitals. Such physician-owned hospitals are restricted, absent waiver authority from CMS, from expanding capacity in terms of the number of operating rooms, procedure rooms, and beds for which the facility was licensed as of March 23, 2010. In order to obtain a waiver of this rule, a hospital must qualify as an “applicable hospital” or a “high Medicaid facility.”

Continue Reading CMS Grants First Waiver of Stark Law Expansion Restrictions—Are More Ahead?

The latest from the Journal of the American Medical Association (JAMA) is a thematic issue organized around a prominent topic in healthcare: price, cost, and competition. Contributing to the debate is an article titled, “Physician Practice Competition and Prices Paid by Private Insurers for Office Visits.”[1] The study is of particular interest because, as the authors note, evidence on the relationship between price and competition in the context of physician services (as opposed to hospitals or insurance companies) is fairly limited.
Continue Reading Exploring the Relationship Between Price and Competition Among Physician Practices

Are medical devices, subject to pre- and post-market regulatory controls, under increasing cybersecurity scrutiny? The FDA recently published recommendations for consideration of cybersecurity management in a product’s design and development phases, and in preparation of pre-market submissions.[1] While the agency emphasizes that it has issued a guidance document containing only nonbinding recommendations, is there an underlying expectation that manufacturers address—and that agency staff assess— such planning as part of the approval process?
Continue Reading Device Advice: New Guidance From the FDA on Medical Devices and Cybersecurity

Anthem Blue Cross and seven competing hospital systems in Southern California are joining forces to establish a new health plan offering, Vivity.[1]  Operating with a combined 14 hospitals and approximately 6,000 physicians, the venture has already announced its first major customer: the State of California’s pension fund manager, the California Public Employees’ Retirement System (CalPERS).
Continue Reading From Competitors to Co-Adventurers, Seven Hospital Systems Join with Anthem Blue Cross to Shake Things Up in Southern California

On August 26th, the Center for Medicare Advocacy filed a nationwide class action lawsuit against the Secretary of Health and Human Services. The complaint alleges that, as implemented, the Medicare administrative review process is in violation of Medicare statutory obligations and the Fifth Amendment’s Due Process Clause.[1]
Continue Reading A (Second) Lawsuit Seeks to Compel Statutory Timeframe for Administrative Law Judge Review of Medicare Claims Appeals

The Centers for Medicare and Medicaid Services (CMS) has approved Pennsylvania’s demonstration proposal to expand Medicaid to adults with incomes through 133 percent of the federal poverty line. The state is the 28th (including D.C.) to pursue Medicaid expansion, and one of a growing number of states to do so under an alternative model developed in collaboration with the federal government.
Continue Reading Pennsylvania gets a green light to pursue Medicaid expansion under an alternative model