Cigna is settling a federal claim for knowingly submitting false diagnosis codes to Medicare Advantage plans. Investigators alleged that Cigna submitted inaccurate and untruthful codes from 2016 to 2021, violating the false claims act. In one example, federal prosecutors said Cigna submitted reimbursement documents for patients who are morbidly obese but did not submit medical records that showed their body mass index being above 35, which is a requirement for that particular diagnosis code.
Medicare Advantage (MA) enrollment has been trending up the last two decades and most of the enrollees are managed by MCO’s. The Medicare Modernization Act of 2003 created stronger financial incentives for plans to participate in the program throughout the country and renamed private Medicare plans Medicare Advantage. In 2023, more than half (51%) of eligible Medicare beneficiaries – 30.8 million people out of 60.0 million Medicare beneficiaries with both Medicare Parts A and B – are enrolled in Medicare Advantage plans.
Contact Access Elite today to learn more about how we can help navigate this for your facility.
Humana will be exiting the Employer Group Commercial Medical Products business, which includes all fully insured, self-funded and Federal Employee Health Benefit medical plans, as well as associated wellness and rewards programs. The exit from this line of business will be phased over the next 18 to 24 months. They plan to focus in the Government sector.
Contact Access Elite today to learn more about how this may affect your facility and how to get prepared.
It looks as though the pandemic will be around for quite some time. Skilled nursing facilities have been forced to rethink how they are providing care. Many are finding they must embrace the change in order to move forward and focus on strategic goals. For more on this, please see the article below.
A recent analysis found a 14% increase in the number of patients being discharged home from skilled nursing facilities. It’s worth noting that this only equates to around one person per month transitioning to the home. Most often, these were patients who had stayed at the nursing home for at least 100 days.
The article below encourages SNFs to better communicate with home health providers when transitioning services. Readmission rates could be affected if the transition isn’t scheduled within 48 hours of discharge. The patients planning to go home may bounce back to the hospital.
For more on this, please see the below.
In order to make more informed decisions and maximize financial gains, providers must embrace data utilization to succeed in the current market.
Access Advantage offers back-office support and troubleshooting for payer operations, contracting, renegotiations, and revenue cycle management. We offer a specialized performance profiling report, our Map to Market (M2M). Let us know if your facility would like to request this today.
For more on this, please also see the article below.
Medicare Part A covers a skilled nursing facility stay only if the individual was admitted for three days at the hospital as opposed to under observation, which is considered outpatient.
This article eloquently explains the difference between being admitted to a hospital versus under observation, what has changed during the pandemic, and what that means with regards to Medicare coverage of a skilled nursing stay.