Payers

On paper, Ozempic (semaglutide) is indicated to help improve glycemic control in adults with type 2 diabetes and reduce risk of cardiovascular events in patients with type 2 diabetes and established cardiovascular disease. Its acclaim in the media and popular culture, however, is much more focused on its corresponding weight loss benefits. Consequently, off-label prescriptions have soared—to the extent that payers are now scrutinizing prescriptions written for patients who are not diabetic. As noted in …

Just a couple of weeks ago, we relayed that an investigation showed Blue Cross Blue Shield of Illinois failed to audit at least 25% of provider directories to ensure they were current and that their website maintained current provider information. The upshot was that your urgent care center might not show up when BCBS members searched for covered practices to visit. Now the Journal of the American Medical Association has published a study revealing that …

Apple is likely to partner with an existing major player as a first step in to the healthcare insurance marketplace in 2024, according to an article published by Forbes. The whole idea seems to bank on the value of the rich data available via the Apple Watch line of products. The question is, how is that asset expected to translate to positive broker relationships and, ultimately, sufficient market share to support the business? History doesn’t …

First the urgent care industry saw itself cut out of the distribution chain for COVID-19 testing supplies. Next, it saw vaccines go preferentially to go health systems, public health organizations, and chain drugstores and big box stores. Now, as it continues to come back from those oversights, there are reports that UnitedHealth Group is undercutting the reimbursement rate set by the Centers for Medicare and Medicaid Services for immunizing patients against SARS-CoV-2. They’re not legally …

When even the headline of one of Yahoo News’s rotating lead stories notes “backlash” against a decision made by a health insurer, it’s not a good week for the company’s image. However, UnitedHealthcare’s announcement that it’s going to start looking long and hard at emergency room visits—and denying or reducing payment on claims deemed to be nonemergent—could wind up benefiting the urgent care industry. In a network bulletin posted on its website, UHC announced it …

Whether or not you’ve participated in the U.S. Department of Health and Human Services’ program to cover the cost of administering COVID-19 tests to uninsured patients to date, take note that HHS is extending the program to include vaccination. The agency is hosting a webinar on Tuesday, April 13 at 2 pm, Eastern to explain the steps for using the program, including how to enroll as a provider participant, check patient eligibility, submit patient information …

The Centers for Medicare & Medicaid Services has instituted a course correction regarding reimbursement for COVID-19 vaccination. As of March 15, CMS has increased the amount from approximately $28 to $40 for the single-dose vaccine and approximately $45 to $80 for those requiring the two-dose schedule. CMS says the decision to increase reimbursement reflects the growing body of information about the actual costs involved in administering the vaccine across different settings by an array of …

When you spend time with a patient and counsel them to self-isolate due to concerns over COVID-19, you’re using the expertise you’ve developed through years of training and treating others. Up until now, however, there’s been no mechanism to reimburse you for that that time, which you could be spending to provide revenue-generating care. Recognizing this, the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention have announced that payment …

The Department of Health and Human Services, under the Families First Coronavirus Response Act and the Coronavirus Aid, Relief and the Economic Security (CARES) Act, has launched a portal specifically designed to ensure healthcare providers who have tested or treated uninsured patients for COVID-19 are compensated for those services. Claims are reimbursed “generally at Medicare rates,” according to HHS. Claims related to care provided on or after February 4, 2020 can be submitted through the …