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The second year of Medicare's Part D benefit began on Jan. 1, 2007, with an updated benefit design and other changes that will have important implications for drug plans, healthcare [...]

A hospital struggles when a joint venture with two long-term care (LTC) providers generates substantially less revenue than was projected. A second hospital is stung when several discharged patients complain [...]

AT A GLANCE Medicare's drug discount card program is expected to help participants save an average of 10 to 15 percent on the cost of outpatient prescription drugs. Many of [...]

Medicare's ambulance fee schedule, which took effect April 1, 2002, has meant higher payments for some providers and suppliers, but lower payments for others. (a) Healthcare financial managers must revise [...]

Starting October 1, 2000, Medicare began paying providers of home health care at fixed, predetermined rates for services and items bundled into 60-day episodes of home health care. The episode [...]

On July 1, 1998, Medicare's cost-related reimbursement method for skilled nursing facility care was replaced with a prospective payment system that includes a case-mix adjustment based-on the Resource Utilization Groups [...]

Since 1997, the method to establish capitation rates for Medicare beneficiaries who are members of risk-bearing managed care plans has undergone several important developments. This includes the factoring of beneficiary [...]

Medicare's hospital outpatient prospective payment system (OPPS) went live on August 1, 2000, after a decade of developmental work. The new system introduced a free schedule that replaced the cost-related [...]

On January 1, 2002, Medicare began to replace its cost-related inpatient reimbursement method for rehabilitation hospitals and rehabilitation units in hospitals with a prospective payment system. Under the new system, [...]

Beginning January 1, 1992, Medicare has relied on a resource-based relative value scale (RBVS) to establish physician fees. Medicare pays 80 percent of the lower of the amount a physician [...]

Medicare payments surpassed an estimated $224 billion in 2000, more than double the amount spent a decade earlier. Roughly 90 percent of the payments in 2000 purchased inpatient and outpatient [...]

Information on the new hospital outpatient prospective payment system (OPPS) under Part B of the Medicare program is offered. Additional information on the new Medicare's OPPS major components, payment rates and hospital eligibility to receive OPPS is also included.

A reduced Medicare payment scheme, designed to create $13 billion in savings over 5 years and mandated to take effect July 1, 1998, is threatening to increase the risks of operating skilled nursing care facilities.

A new capitation method for Medicare which seeks to motivate managed care plans to become Medicare contractors has been established on Jan 1, 1998. The method establishes a minimum rate that is considerably higher compared to the amounts Medicare previously paid in most US counties. The method also minimizes the volatility in the rates and guarantees all participating health plans at least a 2% annual rate increase in the succeeding years., Medicare+Choice or Part C of the Medicare program revamps the method the federal government uses to establish capitation rates for Medicare beneficiaries enrolled in managed care plans.(1) The changes, coupled [...]

The newest Health Plan Employer Data and Information Set (HEDIS) contains information which can be used by health care purchasers and consumers in comparing the services of different managed care plans. HEDIS is a standardized set of measures covering eight different care 'domains' of interest to purchasers and consumers of managed care. The National Committee for Quality Assurance sponsors and maintains the HEDIS., The Health Plan Employer Data and Information Set (HEDIS) provides consumers and purchasers with considerable information about how health maintenance organizations (HMOs) operate and how well they meet their members' [...]

Many patients and physicians believe that managed care organizations (MCOs) are cutting costs at the expense of patient care. They want state legislatures to pass laws regulating the industry. However, MCO executives believe physicians are simply trying to protect their turf. Some areas of discontent between both groups are physician gag rules, drive-through deliveries, any willing provider laws, direct access to specialists, physician financial incentives and disclosure requirements.

MEDICARE/MEDICAID ISSUES About 3.6 million Medicare beneficiaries - 10 percent of the Medicare population - receive Part A and Part B benefits through health maintenance organizations (HMOs). Beneficiaries are spread [...]

Medicaid waiver contracting opportunities are risky, but they continue to attract many managed care organizations. Recommendations to help managed care organizations minimize the risks in such contracts are presented. These include knowing the service content of Medicaid benefits to be covered; computating of capitation rates based on carefully scrutinized Medicaid payment and utilization rate data; computing capitation rates based on data other than those coming from Medicaid; submitting capitation bids based on realistic financial requirements; and ensuring that data and quality assurance information will be available whenever they are needed.