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Tag: RAC

Reporting of All Recovery Auditor-Initiated Claim Adjustments and their Subsequent Adjustments for Periodic Interim Payment (PIP) Facilities

From: CMS Transmittal 1720 (Pub 100-20); 9/23/16


CR 7601 (Transmittal 977) was issued in October 2011, with an implementation of April 2, 2012 and an effective date of April 1, 2012, instructing the Fiscal Intermediary Shared System (FISS) to develop a process for sending Recovery Auditor-initiated Periodic Interim Payment (PIP) claim adjustments to the Healthcare Integrated General Ledger Accounting System (HIGLAS) via the 837 interface. Due to issues with the process, a workgroup was formed in the spring of 2013 to ensure that adjustments were transmitting from FISS to HIGLAS and that transmitted adjustment amounts were accurate. In the summer of 2014, CMS was alerted that this process was specific to 11X bill types, and all other bill types for PIP providers were placed on hold. The purpose of this Change Request is to ensure that all Recovery Auditor-initiated adjustments (11H) to PIP claims and their subsequent adjustments are being correctly reported on the Provider Statistical & Reimbursement (PS&R) Report.

Reporting of All Recovery Auditor-Initiated Claim Adjustments and their Subsequent Adjustments for Periodic Interim Payment (PIP) Facilities

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United Health May Quit Obamacare in Blow to Health Law

From: Bloomberg Business – 11/19/15

Article Excerpt:

The biggest U.S. health insurer is considering pulling out of Obamacare as it loses hundreds of millions of dollars on the program, casting a pall over President Barack Obama’s signature domestic policy achievement.

UnitedHealth Group Inc. has scaled back marketing efforts for plans sold to individuals this year and may quit the business entirely in 2017. It’s an abrupt shift from October, when the health insurer said it was planning to sell coverage through the Affordable Care Act in 11 more states next year, bringing its total to 34. The company also cut its 2015 earnings forecast.

While millions of Americans have gained coverage under Obamacare since new government-run marketplaces for the plans opened in late 2013, in UnitedHealth’s case they haven’t been the most profitable. Customers the company has added have tended to use more medical care. UnitedHealth also said today that some people are signing up for coverage, getting care and then dropping their policies.

“We cannot sustain these losses,” Chief Executive Officer Stephen Hemsley told analysts on a conference call. “We can’t really subsidize a marketplace that doesn’t appear at the moment to be sustaining itself.”

UnitedHealth said it expects as much as $500 million in losses on the Obamacare plans in 2016. The insurer will record $275 million of the costs in the fourth quarter. United also said Thursday it’s booking $350 million in losses tied to the 2015 performance of its ACA plans.

The company’s shares fell 5.6 percent to $110.63 at the close in New York. Anthem Inc. and Aetna Inc., the two biggest health insurers after UnitedHealth, also declined, as did hospital stocks including HCA Holdings Inc. and Community Health Systems Inc.

Insurance markets rely on premiums paid by healthy people to subsidize the medical costs of the sick. If an insurer sets premiums that are too low or attracts customers that are too sick, it can suffer losses. That can be a particular risk in new markets that an insurer may not be as familiar with.

While UnitedHealth has been slower than some of its rivals to sell Obamacare policies, the announcement may indicate that other insurers are struggling, said Sheryl Skolnick, an analyst at Mizuho Securities.

“If one of the largest and presumably, by reputation and experience, the most sophisticated of the health plans out there can’t make money on the exchanges, then one has to question whether the exchange as an institution is a viable enterprise,” Skolnick said.

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CMS Announces Changes to Recovery Audit (RAC) Program

From CHA – 11/9/15

The Centers for Medicare & Medicaid Services (CMS) last week announced important changes to the recovery audit program. Effective Jan. 1, the additional documentation request (ADR) limits for the recovery audit contractors (RACs) will be reduced to one-half of one percent of the hospital’s total number of paid Medicare claims from the previous year. In addition, CMS is establishing future ADR limits based on a provider’s compliance with Medicare rules. Providers with low denial rates will have lower ADR limits, while providers with high denial rates will have higher ADR limits. CMS also released a summary of the past and future scheduled enhancements to the recovery audit program, including reducing the look-back period for patient status reviews to 6 months and requiring RACs to maintain an overturn rate of less than 10 percent at the first level of appeal.

CMS Announces Changes to Recovery Audit (RAC) Program


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