Deal reached on millions in erroneous Medicare payments

Posted on by Terri Lange
Medicare Advantage plans giving back a combined total of $26 million in overpaid funds.

THE PULSE  November 13, 2019 Andy Miller 

Federal health officials have worked out an agreement to resolve an overpayment problem with medical providers in Georgia and other states.

The terms of that agreement, like the payment issue itself, are complicated,

A year ago, Georgia Health News reported that the federal Centers for Medicare & Medicaid Services (CMS) planned to recoup $55 million in improper payments to hospitals and other providers in a few states.

The overall problem started with erroneous reimbursements paid to hospitals, rural health clinics and other providers by Cahaba GBA, a former Medicare Administrative Contractor. CMS cited 268,000 claims paid in error through the traditional Medicare program over at least four years.

The federal agency said the patients served in these instances were members of a Medicare Advantage program, run by private insurers, and it said those health plans had the responsibility to pay the hospitals.

Georgia providers topped the list with repayments due of $19.1 million, followed by $15.4 million in Tennessee, and $11.9 million in Alabama. Another $8.3 million comes from other states.

Cahaba GBA “made errors that led to significant overpayments,’’ CMS said last year. The mistaken payments involved mainly hospital outpatient claims.

“The government error has brought confusion and administrative costs and burden to already cash-starved hospitals for a mistake that was not theirs,” said Jimmy Lewis, CEO of HomeTown Health, an association of rural hospitals in the state.

The dispute’s resolution has emerged recently. It includes many Medicare Advantage plans giving back to the feds a combined total of $26 million in overpaid funds, resolving 133,000 erroneous claims.

A second group of Advantage plans agreed to allow providers to re-bill their claims with these insurers or otherwise pursue payments.

A third group of these Medicare insurers have not agreed to cooperate with these efforts, and about half of the affected claims are still subject to recovery by the new Medicare contractor, Palmetto GBA. To address these claims, CMS is offering a settlement with hospitals to recover 40 percent of the total payments.  This situation leaves about $12 million of the overall overpayments unresolved.

The Georgia Hospital Association (GHA) said Wednesday that it “appreciates the work by the Centers for Medicare and Medicaid Services over the last year to mitigate the impact on Georgia’s hospitals of the claims processing errors by Cahaba.’’

“We are disappointed, however, that not all of the Medicare Advantage Plans are willing to take financial responsibility for the medically necessary hospital services provided to their beneficiaries as requested by CMS,’’ said Ethan James, a GHA executive. “Hospitals followed the established claim procedures in good faith. Requiring repayment for legitimate and appropriate care provided to patients will significantly impede hospitals’ ability to provide care to all patients. This will be especially true for Georgia’s small and rural hospitals.’’

The agency did not disclose the names of the hospitals or other providers that received the “overpayment” letters.

What is your local hospital grade?

Posted on by Terri Lange

One in four Georgia hospitals earned an “A’’ grade in the latest safety ratings by the Leapfrog Group, released Thursday.

That percentage is lower than the one-third of Georgia hospitals scoring an A in the spring 2019 Leapfrog report. The new rate dropped Georgia from 15th among states to 34th for its percentage of hospitals getting a top grade.

Leapfrog, a patient safety organization founded by employers, issues the rankings semi-annually, in fall and spring. It’s a widely watched rating system, and is touted by hospitals that do well in the grades. Read More

Wellcare Adds Piedmont Healthcare to Network Providers

Posted on by Terri Lange

WellCare Medicare Advantage, Medicaid and PeachCare for Kids® members now have in-network access to Piedmont Healthcare. 

Piedmont Healthcare is an integrated healthcare system of 11 hospitals, 27 urgent care centers, 28 Piedmont QuickCare locations and 555 clinic practices that reach 70% of Georgia’s population.

Current members of WellCare’s MA Health Maintenance Organization (HMO) plans, and Preferred Provider Organization (PPO) plans and those who enroll in WellCare’s Medicare Advantage health plan’s during 2020 Medicare open enrollment will also have in-network access to the health system.

“At WellCare, our members’ health is our top priority. We are thrilled to partner with Piedmont Healthcare to offer our members access to affordable, high-quality healthcare to help them live better, healthier lives,” said Sonya Nelson, WellCare’s state president in Georgia.

WellCare’s members now have access to all 11 Piedmont Healthcare hospitals, including its three clinical hubs: Piedmont Atlanta Hospital, a 643-bed hospital, recently named one of 100 Great Hospitals in America by Becker’s Healthcare; Piedmont Athens Regional, a 359-bed hospital, named Georgia’s Top Teaching Hospital by the Leapfrog Group in 2018; and Piedmont Columbus Midtown, a 583-bed hospital, with west Georgia region’s only full-range cancer center, Level II trauma program and children’s Hospital with level III NICU.

As of Sept. 30, 2019, WellCare serves approximately 492,000 Medicaid and PeachCare for Kids® plan members, 52,000 Medicare Advantage plan members and 26,000 Medicare Prescription Drug Plan members in Georgia. To learn more about how we care for Georgians watch Gloria’s story at http://youtu.be/qyn-nywze04.

SOURCE WellCare Health Plans, Inc.

Employers Are Looking At Lower Deductibles For Employer Health Insurance

Posted on by Terri Lange

Employers Are Scaling Back Their Dependence On High-Deductible Health Plans

Michelle Andrews

Everything old is new again. As open enrollment gets underway for next year’s job-based health insurance coverage, some employees are seeing traditional plans offered alongside or instead of the plans with sky-high deductibles that may have been their only choice in the past.

Some employers say that, in a tight labor market, offering a more generous plan with a deductible that’s less than four figures can be an attractive recruitment tool. Plus, a more traditional plan may appeal to workers who want more predictable out-of-pocket costs, even if the premium is a bit higher.

That’s what happened at Digital River, a 650-person global e-commerce payment processing business based in Minnetonka, Minn.

Four years ago, faced with premium increases approaching double digits, Digital River ditched its traditional preferred provider organization plan in favor of three high-deductible plans. Each had different deductibles and different premiums, but all linked to health savings accounts that are exempt from taxes. This year, though, the company added back two traditional preferred provider plans to its offerings for workers.

Even with three plan options, “we still had employees who said they wanted other choices,” said KT Schmidt, the company’s chief administrative officer.

Digital River isn’t the only company broadening its offerings. For the third year in a row, the percentage of companies that offer high-deductible plans as the sole option will decline in 2020, according to a survey of large employers by the National Business Group on Health. A quarter of the firms polled will offer these plans, sometimes called consumer-directed plans, as the only option next year, down 14 percentage points from two years ago.

That said, consumer-directed plans are hardly disappearing. Fifty-eight percent of covered employees worked at companies that offered at least one high-deductible health plan in 2019, according to an annual survey of employer health benefits released by the Kaiser Family Foundation last month. That was second only to the 76% of covered workers who were at firms that offered a PPO plan. (KHN is an editorially independent program of the foundation.)

When Digital River switched to all high-deductible plans for 2016, the firm put some of the $1 million it saved into the new health savings accounts that employees could use to cover their out-of-pocket expenses before reaching the deductible. Employees could also contribute to those accounts to save money for medical expenses. This year the deductibles on those plans are $1,850, $2,700 and $3,150 for single coverage, and $3,750, $5,300 and $6,300 for family plans.

The company put a lot of effort into educating employees about how the new plans worked, said Schmidt. Premiums are typically lower in high-deductible plans. But under federal rules, until people reach their deductible, the plans pay only for specified preventive care such as annual physicals and cancer screenings and some care for existing chronic conditions.

Enrollees are on the hook for everything else, including most doctor visits and prescription drugs. In 2020, the minimum deductible for a plan that qualifies under federal rules for a tax-exempt health savings account is $1,400 for an individual and $2,800 for a family.

As their health savings account balances grew, “more people moved into the camp that could see the benefits” of the high-deductible strategy, Schmidt said. Still, not everyone wanted to be exposed to costs upfront, even if they ended up spending less overall.

“For some people, there remained a desire to pay more to simply have that peace of mind,” he said.

Digital River’s PPOs have deductibles of $400 and $900 for single coverage and $800 and $1,800 for families. The premiums are significantly more expensive than those of the high-deductible plans.

In the PPO plan with the $400/$800 deductible, the employee’s portion of the monthly premium ranges from $82.37 for single coverage to $356.46 for an employee plus two or more family members. The plan with the $2,700 deductible costs an employee $21.11 for single coverage and the $5,300 deductible plan costs $160.29 for the employee plus at least two others.

But costs are more predictable in the PPO plan. Instead of owing the entire cost of a doctor visit or trip to the emergency room until they reach their annual deductible, people in the PPO plans generally owe set copayments or coinsurance charges for most types of care.

When Digital River introduced the PPO plans this year, about 10% of employees moved from the high-deductible plans to the traditional plans. Open enrollment for 2020 starts later this fall, and the company is offering the same mix of traditional and high-deductible plans again for next year.

Adding PPOs to its roster of plans not only made employees happy but also made the company more competitive, Schmidt said. Two of Digital River’s biggest competitors offer only high-deductible plans, and the PPOs give Digital River an edge in attracting top talent, he believes.

According to the survey by the National Business Group on Health, employers that opted to add more choices to what they offered employees typically chose a traditional PPO plan. Members in these plans generally get the most generous coverage if they use providers in the plan’s network. But if they go out of network, plans often cover that as well, though they pay a smaller proportion of the costs. For the most part, deductibles are lower than the federal minimum for qualified high-deductible plans.

Traditional plans like PPOs also give employers more flexibility to try different approaches to improve employees’ health, said Tracy Watts, a senior partner at benefits consultant Mercer.

“Some of the newer strategies that employers want to try just aren’t [health savings account] compatible,” said Watts. The firms might want to pay for care before the deductible is met, for example, or eliminate employee charges for certain services. Examples of these strategies could include direct primary care arrangements in which physicians are paid a monthly fee to provide care at no cost to the employee, or employer-subsidized telemedicine programs.

The so-called Cadillac tax, a provision of the Affordable Care Act that would impose a 40% excise on the value of health plans that exceed certain dollar thresholds, was a driving force behind the shift toward high-deductible plans. But the tax, originally supposed to take effect in 2018, has been pushed back to 2022. The House passed a bill repealing the tax in July, and there is a companion bill in the Senate.

It’s unclear what will happen, but employers appear to be taking the uncertainty in stride, said Brian Marcotte, president and CEO of the National Business Group on Health.

“I think employers don’t believe it’s going to happen, and that’s one of the reasons you’re seeing [more plan choices] introduced,” he said.