Reimbursement

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Class action book and gavel | Image credit: Zerbor – stock.adobe.com

GoodRx, PBMs Hit by Price Fixing Lawsuits

November 5th 2024

Independent pharmacies have filed 3 class action lawsuits against GoodRx Holdings and major pharmacy benefit managers (PBMs).

Screenshot of an interview with Stuart Staggs

The Challenge of Addressing Drug Spend to Drive Down Total Cost of Care in EOM

By Laura Joszt, MA

October 27th 2024

Stethoscope on money | Image credit: utah51 - adobe.stock.com

Pressure on Congress to Reform Medicare Physician Fee Schedule, Prevent Reimbursement Cuts

By Laura Joszt, MA

October 17th 2024

The Daily Balancing Act of Value-Based Cancer Care

By Laura Joszt, MA

October 14th 2024

Doing Things Differently: Wilfong Moves to Thyme Care

By Mary Caffrey

October 12th 2024

More News

Calculator and stethoscope on financial sheets | Image credit: Brian Jackson - stock.adobe.com.jpeg

December 1st 2023

Hospitals Report Declining Cash Reserves, Increasing Reimbursement Delays and Denials

Laura Joszt, MA

A new report highlighting the twin pressures hospitals have faced over the last 18 months shows that as reimbursement delays and denials increased and cash and investments decreased, operating expenses have risen sharply.

Stethoscope on money | Image credit: utah51 - stock.adobe.com

November 20th 2023

AMA Continues Call for Medicare Payment System Fix During Interim Meeting

Laura Joszt, MA

The American Medical Association (AMA) is continuing to urge Congress to stop the impending 3.4% cut to physicians, and other organizations also weigh in on the pros and cons of the 2024 Medicare Physician Fee Schedule.

November 15th 2023

What We’re Reading: UnitedHealth Lawsuit; Fentanyl Crackdown; Global Heat Deaths Increase

AJMC Staff

A class action lawsuit was filed against UnitedHealth Group and a subsidiary for allegedly using an algorithm to deny rehabilitation coverage for seriously ill patients; US and China officials are finalizing an agreement to crack down on fentanyl; a study published Tuesday projected global heat deaths to increase by 370% if no action is taken against global warming.

November 8th 2023

All-Payer Value-Based Contracting in Organizations With Medicare ACOs

Robert E. Mechanic, MBA

This 2022 survey of Medicare accountable care organizations (ACOs) shows significant growth in non-Medicare value-based contracts and in contracts with downside risk.

November 4th 2023

EOM Shows Awareness of Issues, but Provides No Resources, Says COA’s Nicolas Ferreyros

Laura Joszt, MA Maggie L. Shaw

The Enhancing Oncology Model is trying to address a number of the systemic challenges oncology faces without giving practices the tools and resources they need, said Nicolas Ferreyros, managing director of policy, advocacy, and communications, Community Oncology Alliance.

November 3rd 2023

Impact of Including Drug Spending in Oncology Alternative Payment Models

Luca Maini, PhD Jacob P. Klimek, PhD David C. Johnson, MD, MPH George M. Holmes, PhD Darren A. DeWalt, MD, MPH

This study demonstrates a method for understanding the effects of drug spending in the design of alternative payment models.

November 3rd 2023

Contributor: Preparing for Massive MTM Program Expansion—Pharmacy-Led Medical Cost Savings to Fund CMS Changes

Jason Z. Rose, MHSA

Changes in the medication therapy management (MTM) program willl require planning on how to best fund this program in a way that drives medical cost savings.

November 2nd 2023

Congress Must Protect Physicians From Medicare Cuts: MGMA

Richard Payerchin

The Medical Group Management Association offers an analysis of pending legislation that could help health care practices better serve patients.

October 25th 2023

COA’s Policy Agenda Gains Steam on Capitol Hill, as the House Elects a Speaker

Mary Caffrey

There is bipartisan support in the Congress for the Community Oncology Alliance's (COA) key agenda items, with hope that some will pass by year’s end.

October 24th 2023

Confronting the Dynamics of Medicare Benefits When Those Eligible Are Still Working

Mary Caffrey

Community oncology practices are witnessing a new dynamic in which more Medicare-eligible patients are still covered by commercial insurance, according to speakers at the Community Oncology Alliance Payer Exchange Summit, held October 23-24, 2023.

October 20th 2023

The Challenges of Treating Cancer When the Patient Lives Far From Care

Peter Page

October 17th 2023

Christine Pfaff on Ensuring Patient Access to Affordable Treatments

Laura Joszt, MA Maggie L. Shaw

To ensure patients are getting timely access to their treatments, there needs to be better collaboration between payers and providers, said Christine Pfaff, RPh, senior regional director of operations, American Oncology Network.

Kenneth Endo, MHA, BS, RTT | Image Credit: PIH Health Whittier Hospital

October 13th 2023

Oncology Financial Navigator Ensures Vital Care Access, Eases Economic Burden

Maggie L. Shaw

According to the National Cancer Institute, in the year following a cancer diagnosis, the average cost of medical care plus medication exceeds $42,000, with some treatments having a price tag of more than $1 million.

Health insurance concept using blocks with icons | Image credit: REDPIXEL - stock.adobe.com

October 7th 2023

Cigna to Pay $172M to Settle Claims of Wrongful Reimbursement by Medicare Advantage

Richard Payerchin

Cigna will pay $172 million to resolve allegations that it submitted inaccurate diagnosis codes for Medicare Advantage plan enrollees in order to increase payments from Medicare.

October 6th 2023

Dr Rajini Katipamula-Malisetti: Minnesota Oncology Takes Value Very Seriously

Brooke McCormick

Rajini Katipamula-Malisetti, MD, executive vice president of Minnesota Oncology, defined value-based cancer care and its importance.

October 6th 2023

COA: Inflation Cut Value of Medicare Payments by 28% Over Decade

AJMC Staff

The effects of flat or reduced reimbursements alongside inflation have been quantified in a report by Avalere Health, prepared for the Community Oncology Alliance (COA.)

October 3rd 2023

US Oncology Network’s Rhonda Henschel Discusses Value-Based Care, Payer Relations Initiatives

Brooke McCormick

Rhonda Henschel, US Oncology Network's vice president of payer relations, summarized what she learned from the Minnesota Oncology IVBM and discussed new developments in the value-based cancer care space.

Nicolas Ferreyros, Community Oncology Alliance

September 27th 2023

Collaboration Is Key to Success in Alternative Payment Models, Says COA’s Nick Ferreyros

Maggie L. Shaw

The number one ingredient that an oncology-based alternative payment model needs to succeed is collaboration, explained Nicolas Ferreyros, managing director of policy, advocacy, and communications, Community Oncology Alliance (COA).

September 25th 2023

Contributor: MA Plans Can Leverage Advanced Technology to Shore Up Risk Adjustment Practices

Karen Kobelski, MBA

Faced with new government regulations, Medicare Advantage (MA) organizations should be utilizing technology to increase the accuracy of their coding, mitigate their risk, and ensure appropriate care for members.

Nick Ferreyros, Community Oncology Alliance

September 20th 2023

COA’s Nick Ferreyros Addresses Oncology Policy Changes and the IRA

Maggie L. Shaw

We are in the midst of a transformative time in oncology that could also be a little scary if you are not prepared, said Nicolas Ferreyros, managing director of policy, advocacy, and communications, Community Oncology Alliance.

Jackson Williams, JD | Image Credit: Dialysis Patient Citizens

September 17th 2023

Contributor: Medicare’s Leadership Needs to Confront Our Shrinking US Workforce

Jackson Williams, JD

Medicare’s administered pricing system has never had to deal with labor scarcity before.

September 13th 2023

New CMMI Model Supports Health Equity in States, Shifts Care to the Community

Laura Joszt, MA

The AHEAD Model will operate for 11 years and aim to shift health care to community-based settings.

Andre Harvin, PharmD, MS, MBA, Cone Health Cancer Centers

September 10th 2023

Dr Andre Harvin: Specialty Pharmacists Are Integral to Oncology Care

Maggie L. Shaw

Specialty pharmacy is a big area of growth, with opportunity for patients, and specialty pharmacists can help payers and insurers ensure that patients get the full value of oncology medications, noted Andre Harvin, PharmD, MS, MBA, chief pharmacy officer, Oncology Services, Cone Health Cancer Centers.

G.B. John Mancini, MD, University of British Columbia

September 7th 2023

Dr G. B. John Mancini on Payer System Differences Between the US and Canada

Maggie L. Shaw

Care quality is high in both the United States and Canada, but there are commonalities in regard to drug access and cost issues, particularly with advanced medications, noted G. B. John Mancini, MD, University of British Columbia.

September 3rd 2023

MSSP ACOs Saved $1.8M in 2022, Report Sixth Consecutive Year of Savings

Laura Joszt, MA

The Medicare Shared Savings Program (MSSP) generated its second highest annual savings since the program began more than a decade ago.

August 30th 2023

Contributor: ACO Success—Driving Better Outcomes and Liberating Clinicians

Steven Reeves, MD, FACP

Physicians have been facing increasing workloads making it difficult to practice medicine as they were trained, but an accountable care organization might provide an opportunity for real change to deliver high-value, compassionate care.

August 29th 2023

CMS Releases List of 10 Drugs Subject to Price Negotiation Under IRA

Christina Mattina

The 10 drugs, spanning disease states from diabetes to heart failure to rheumatoid arthritis, cost Medicare enrollees a total of $3.4 billion in out-of-pocket costs in 2022. As required by the Inflation Reduction Act (IRA), negotiations between Part D and pharmaceutical companies will take place this year and next, with the negotiated prices taking effect in 2026.

August 23rd 2023

What We’re Reading: Insurers Publicly Shamed; HHS Grants for COVID-19 Countermeasures; Medicare Obesity Drug Coverage

AJMC Staff

Patients and physicians are publicly shaming insurance companies on social media for the troublesome prior authorization process; HHS has awarded $1.4 billion in grants for the creation of new technologies and tools to prevent COVID-19 infection; Novo Nordisk has increased lobbying efforts to allow Medicare coverage of weight loss drugs.

August 23rd 2023

Hospital Performance in a Statewide Commercial Insurer Episode-Based Incentive Program

Michael P. Thompson, PhD Anne H. Cain-Nielsen, MS Monica L. Yost Karslake, MPH Chelsea A. Pizzo, MPH Jessica M. Yaser, MPH John D. Syrjamaki, MPH Hari Nathan, MD, PhD Edward C. Norton, PhD Scott E. Regenbogen, MD, MPH

Some hospitals were able to outperform others in a commercial insurer episode-based incentive program, but there was little evidence of global reductions in episode spending.

August 22nd 2023

Dialysis Costs for a Health System Participating in Value-Based Care

Leslie P. Wong, MD, MBA Anindita Ghosh, MD Jianbo Li, PhD Maged K. Rizk, MD, MBA Jessica A. Hohman, MD, MSc

In a large, integrated health system participating in value-based care, higher costs and utilization were observed before and after unplanned dialysis initiation.

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