2025 MEDICARE: Agent & Broker Pay Day Changes

Posted on December 7, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

How insurance agents will be compensated for helping seniors?

By Staff Reporters

***

***

Health insurance agents offering support to seniors signing up for healthcare coverage will be compensated differently starting in 2025. For example:

The government will pay $100 more per enrollment to agents who sign seniors up for Medicare Advantage Plans or Medicare Part D for the first time — a significant increase from the proposed $31 pay increase for agents.

And, Medicare is ending sales incentives for agents who currently receive bonuses, including volume-based bonuses, for signing people up for Medicare Advantage Plans, Medigap Supplement Plans or Part D. Medicare is also putting a stop to agents and brokers collecting “administrative fees” above the fixed compensation cap the government has put in place.

The hope is that providing agents with fair initial compensation will no longer incentivize them to steer seniors towards plans that may not be a good fit.

CITE: https://www.r2library.com/Resource/Title/0826102549

PS: Medicare open enrollment ended December 7th, 2024. New plans commence January 1st, 2025

COMMENTS APPRECIATED

Subscribe and Refer!

Thank You

***

***

Filed under: "Ask-an-Advisor", Drugs and Pharma, Ethics, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance | Tagged: , , , , , , , , , , , , | Leave a comment »

IN & OUT OF NETWORK: Medical Care

Posted on November 2, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Dr. David Edward Marcinko MBA MEd CMP™

SPONSOR: http://www.CertifiedMedicalPlanner.org

***

***

What does in-network mean?

In-network refers to a health care provider that has a contract with your health plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, you pay a lower cost-sharing when you receive services from an in-network doctor.

What does out-of-network mean?

Out-of-network refers to a health care provider who does not have a contract with your health insurance plan. If you use an out-of-network provider, health care services could cost more since the provider doesn’t have a pre-negotiated rate with your health plan. Or, depending on your health plan, the health care services may not be covered at all.

CITE: https://www.r2library.com/Resource/Title/0826102549

***

OUT OF NETWORK [OON] MEDICAL CARE

Classic: Any medical provider, supplier or facility that is in-network is one that has contracted with your health insurer to provide services;as above.

Modern: Depending on your plan, if you visit an out-of-network provider, it may not be covered or might be only partially covered. When making appointments with various doctors and service providers, you may notice some are listed as “in-network” while others are “out-of-network.”

THINK: Medicare Advantage {Part C] Plans

Example: You can expect a higher deductible and out-of-pocket limit at out-of-network providers. Your coinsurance and co-payment may also be higher for out-of-network providers.

COMMENTS APPRECIATED

Subscribe Today!

***

***

Filed under: Accounting, CMP Program, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, iMBA, Inc., Managed Care, Touring with Marcinko | Tagged: , , , , , , , , , , , , , | Leave a comment »

DAILY UPDATE: Maximum Lifespan as Medicare Part C is Down and Stocks Markets Decline

Posted on October 16, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

***

Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

“Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily“

A Partner of the Institute of Medical Business Advisors , Inc.

http://www.MedicalBusinessAdvisors.com

SPONSORED BY: Marcinko & Associates, Inc.

***

http://www.MarcinkoAssociates.com

Daily Update Provided By Staff Reporters Since 2007.
How May We Serve You?
© Copyright Institute of Medical Business Advisors, Inc. All rights reserved. 2024

REFER A COLLEAGUE: MarcinkoAdvisors@msn.com

SPONSORSHIPS AVAILABLE: https://medicalexecutivepost.com/sponsors/

ADVERTISE ON THE ME-P: https://tinyurl.com/ytb5955z

Your Referral Count -0-

Maximum lifespans. The upper limit of human life expectancy is leveling out, according to a new study published in the journal Nature Aging. Back in 1990, life-extending tech and health measures were increasing the average global lifespan by about 2.5 years per decade, but that dropped to 1.5 years per decade in the 2010s and closer to zero in the US, where there are more drug overdoses, shootings, and medical care inequities.

CITE: https://www.r2library.com/Resource

STOCKS UP

Sphere Entertainment popped 6.33% on the news that a second Sphere will be built in Abu Dhabi. London was originally supposed to be the location of a second venue, but they’ve already got the Eye, and didn’t need more circular tourist attractions.

  • Oklo, a Sam Altman-backed nuclear energy startup, rose another 16.04% on the news that Google will purchase nuclear power to turbocharge its AI infrastructure.
  • Charles Schwab climbed 6.10% after the bank announced a top and bottom line beat last quarter, as well as higher revenue projections for the full fiscal year.
  • Boeing somehow gained 2.26% after announcing it is raising $35 billion to support its struggling finances as the machinist union strike enters its second month.
  • Wolfspeed, which sounds like a super power in a YA novel, soared 21.27% on the news that the US government will provide the chipmaker with up to $750 million in government grants.

STOCKS DOWN

  • Semiconductor stocks got a double whammy in the last 48 hours. First, Bloomberg revealed that US officials are considering limiting the sale of AI chips outside the country. Then, ASML missed its Q3 sales estimates (more on that below). Nvidia shares slid 4.52%, AMD fell 5.22%, and Intel dropped 3.33%.
  • Citigroup beat earnings estimates this quarter, but shareholders punished the bank for setting aside more money in case of higher loan losses ahead. Shares dropped 5.11%.
  • Coty, parent company of numerous beauty brands like CoverGirl, fell 10.74% to a new 52-week low after it warned of a sales slowdown in the coming quarters.
  • Enphase Energy tumbled 9.29% after RBC analysts downgraded the solar power stock, citing growing competition from the likes of Tesla as well as slowing demand for solar batteries.
  • Speaking of energy, oil stocks plummeted on news of Israel’s targeting of Iranian military assets rather than crude production facilities. Exxon Mobil fell 3.01%, Chevron dropped 2.67%, and Valero Energy sank 4.62%.

CITE: https://tinyurl.com/2h47urt5

Here’s where the major benchmarks ended yesterday:

  • The S&P 500® index (SPX) fell 44.59 points (–0.76%) to 5,815.26; the Dow Jones Industrial Average® ($DJI) dropped 324.80 points (–0.75%) to 42,740.42; and the NASDAQ Composite® ($COMP) lost 187.09 points (–1.01%) to 18,315.59.
  • The 10-year Treasury note yield (TNX) fell three basis points to 4.04%, the lowest close in a week.
  • The CBOE Volatility Index® (VIX) climbed to 20.72, an elevated level.

CITE: https://tinyurl.com/tj8smmes

Millions of seniors will lose access to their Medicare Advantage plans after major insurer cuts in the aftermath of the Inflation Reduction Act. Experts spoke with Newsweek about what’s going on and what steps seniors can take to get the coverage they need.

COMMENTS APPRECIATED

PLEASE SUBSCRIBE: MarcinkoAdvisors@msn.com

Thank You

***

***

***

***

EDUCATIONAL TEXTBOOKS: https://tinyurl.com/4zdxuuwf

***

Filed under: Information Technology, Investing, Marcinko Associates, Recommended Books, Sponsors | Tagged: , , , , , , , , , , , , , , , , , , | Leave a comment »

UNITEDHEALTHGROUP: Recent Pros and Cons of UNH

Posted on October 10, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

***

SPONSOR: http://www.MarcinkoAssociates.com

A class action lawsuit has been filed in Minnesota against UnitedHealth Group (NYSE:UNH) over allegations that the health insurer and its subsidiary, NaviHealth, used a faulty algorithm to deny rehabilitation care for Medicare Advantage beneficiaries. California-based Clarkson Law Firm filed the lawsuit in the U.S. District Court of Minnesota on Tuesday following an investigative report published by the health-focused news site Stat.

It alleges that UnitedHealth and its subsidiary, NaviHealth, used the computer algorithm named nH Predict to “systematically deny claims” of patients recovering from debilitating illnesses in nursing homes. According to the lawsuit, despite its 90% error rate, the company used the algorithm to deny claims, knowing that only 0.2% would appeal its decision. According to Stat, Humana (HUM), the nation’s second-largest player in the Medicare Advantage market behind UnitedHealth (UNH), also uses nH Predict. UnitedHealth (UNH) denied it used the NaviHealth predict tool to arrive at coverage decisions.

***

***

Ironically, UnitedHealth’s (NYSE:UNH) Optum Rx unit announced plans to move eight insulin products to “preferred” status on formularies to further expand the number of patients benefiting from $35 or less monthly out-of-pocket costs for the lifesaving therapy.

Optum Rx, UNH’s pharmacy benefit manager (PBM), said that effective January 1, 2024, all short- and rapid-acting insulins will move to Tier 1 in commercial formularies, a list of drugs the company maintains to indicate coverage for insured patients.

CITE: https://www.r2library.com/Resource

COMMENTS APPRECIATED

Thank You

***

***

Filed under: "Doctors Only", Alternative Investments, Drugs and Pharma, Ethics, Financial Planning, Funding Basics, Glossary Terms, Health Economics, Health Insurance, Investing, Marcinko Associates, Touring with Marcinko | Tagged: , , , , , , , , , , , , , , , , | Leave a comment »

DAILY UPDATE: Medicare Part C & Healthcare Bankruptcies as Stock Market Volatility Rises

Posted on August 21, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

MEDICAL EXECUTIVE-POST – TODAY’S NEWSLETTER BRIEFING

***

Essays, Opinions and Curated News in Health Economics, Investing, Business, Management and Financial Planning for Physician Entrepreneurs and their Savvy Advisors and Consultants

“Serving Almost One Million Doctors, Financial Advisors and Medical Management Consultants Daily“

A Partner of the Institute of Medical Business Advisors , Inc.

http://www.MedicalBusinessAdvisors.com

SPONSORED BY: Marcinko & Associates, Inc.

***

http://www.MarcinkoAssociates.com

Daily Update Provided By Staff Reporters Since 2007.
How May We Serve You?
© Copyright Institute of Medical Business Advisors, Inc. All rights reserved. 2024

REFER A COLLEAGUE: MarcinkoAdvisors@msn.com

SPONSORSHIPS AVAILABLE: https://medicalexecutivepost.com/sponsors/

ADVERTISE ON THE ME-P: https://tinyurl.com/ytb5955z

Your Referral Count -0-

Unlike previous election cycles, members of both political parties are skeptical of Medicare Advantage, prompting former HHS Secretary Alex Azar to say plans need to engage in “myth busting.”

Mass General Brigham is showing a slight year-over-year financial improvement across the first half of 2024.

And … a decline in healthcare bankruptcies appears to be driven by middle-market companies.

CITE: https://www.r2library.com/Resource

What’s up

What’s down

  • Lowe’s sank 1.18% after beating earnings expectations but missing on sales and, more importantly, announcing weaker sales lie ahead.
  • Paramount Global stumbled 1.08% after a new $4.3 billion bid to acquire the company came out of left field.
  • Boeing fell 4.24% on the announcement that the company is grounding its test fleet of the new 777X airplane due to, what else, maintenance issues.

CITE: https://tinyurl.com/2h47urt5

Here’s where the major benchmarks ended:

  • The SPX fell 11.13 points (–0.20%) to 5,597.12; the Dow Jones Industrial Average® ($DJI) dropped 61.56 points (–0.15%) to 40,834.97; the NASDAQ Composite®($COMP) ended 59.83 points lower (–0.33%) to 17,816.94.
  • The 10-year Treasury note yield (TNX) fell five basis points to 3.82%.
  • The CBOE Volatility Index® (VIX) climbed 8% to 15.84

CITE: https://tinyurl.com/tj8smmes

Visualize: How private equity tangled banks in a web of debt, from the Financial Times.

COMMENTS APPRECIATED

PLEASE SUBSCRIBE: MarcinkoAdvisors@msn.com

Thank You

***

***

***

***

EDUCATIONAL TEXTBOOKS: https://tinyurl.com/4zdxuuwf

***

Filed under: Information Technology, Investing, Marcinko Associates, Recommended Books, Sponsors | Tagged: , , , , , , , , , , , , | Leave a comment »

PHYSICIANS: Is $2.5 Million “Really” Enough to Retire at Age 65?

Posted on June 5, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

SPONSOR: http://www.MarcinkoAssociates.com

DOCTORS ARE DIFFERENT: https://marcinkoassociates.com/doctors-unique/

***

***

Is $2.5 Million Really Enough to Retire?

A retirement nest egg of $2.5 million can likely produce an annual income of $100,000 for as long as you are likely to live. This is using the 4% withdrawal rate many financial advisors consider standard. After starting with the first withdrawal of 4% of the total, the annual withdrawal will adjust for inflation. For example, if inflation runs at the target 2% rate of federal policymakers, during retirement the retiree will withdraw:

$100,000

in the first year

$102,000

in the second year

$104,040

in the third year and so on …

According to this model and conventional wisdom, a 4% withdrawal rate will allow a portfolio to last for at least 30 years. This would permit a 65-year-old retiree to maintain consistent purchasing power until age 95 and beyond.

For most retirees, this will likely be adequate to maintain a satisfying standard of living. Only about 3% of 2,000 retirees surveyed by the Employee Benefit Research Institute in 2022 spent $7,000 or more per month, equivalent to $84,000 in annual spending.

This model does not include a number of other factors. For instance, nearly all retirees are eligible for Social Security. For 2023, the maximum monthly Social Security benefit for people who claim benefits at full retirement age is $3,627. That’s equal to more than half the spending of the top 3% of retirees surveyed by EBRI. And, like the standard withdrawal rate, Social Security benefits are indexed to inflation.

5 Variables for Retiring With $2.5 Million at Age 65

While $2.5 million could seem like enough to retire at 65, many factors could change the outlook.

1. Unexpected Healthcare Costs

The Fidelity Retiree Health Care Cost Estimate suggests an average 65-year-old couple could need (approximate, after taxes):Unexpected Healthcare Costs

This assumes both spouses are enrolled in traditional Medicare, which between Medicare Part A and Part B covers expenses such as hospital stays, doctor visits and services, physical therapy, lab tests and more, and in Medicare Part D, which covers prescription drugs.

This figure does not include long-term care (“custodial care”), most dental care, eye exams and more, so your estimated healthcare costs in retirement could be considerably more.

2. Inflation

Inflation can powerfully influence retirees’ financial well-being. When inflation occurs, it reduces the purchasing power of money withdrawn from your retirement account. You can increase withdrawals to maintain purchasing power, but this risks more quickly depleting your savings.

3. Market Downturns

Inflation isn’t the only cause of market downturns. Business cycles and financial crises can exaggerate normal fluctuations in stock market valuations. If you’re selling investments to generate income for living expenses, you may want to sell more if valuations are down.

4. Longevity

While living a long life is positive, you could outlive the money you’ve saved for retirement. Many financial planners use life expectancy to age 95 or 100 when developing plans for funding retirement.

The Social Security Administration says an average 65-year-old male can live to age 83, while the average woman can live to age 86. However, people in their 80s and 90s also generally reduce their spending, with the exception of healthcare costs.

5. Estate Planning

Retiring at 65 with $2.5 million likely involved generating high income and savings, so there’s a chance you could have assets to pass on. With estate planning, adding members of your family as beneficiaries for homes you paid off with a mortgage may have long-term positives.

You may also want to think about any additional income streams. For example, if you own a medical practice or business, you may want to add your family as a beneficiary so they can decide to keep the business running or sell it.

CITE: https://www.r2library.com/Resource

COMMENTS APPRECIATED

Thank You

***

***

***

Filed under: Estate Planning, Financial Planning, iMBA, Inc., Investing, LifeStyle, Retirement and Benefits | Tagged: , , , , , , , , , , , | Leave a comment »

PODCAST: Traditional Medicare V. Medicare Advantage

Posted on May 2, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Eric BrickerMD

***

***

COMMENTS APPRECIATED

Thank You

***

***

***

Filed under: Experts Invited, Health Economics, Health Insurance, Healthcare Finance, Videos | Tagged: , , , , | Leave a comment »

DAILY UPDATE: Medicare Payment Policy and Inflation as the Stock Markets Gain

Posted on March 20, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

***

***

MEDICARE: https://www.medpac.gov/wp-content/uploads/2024/03/Mar24_MedPAC_Report_To_Congress_SEC.pdf

The producer price index (PPI) rose 0.6% for the month, according to the Bureau of Labor Statistics—double the Dow Jones estimate, CNBC reported. February’s larger-than-expected PPI uptick follows a more modest 0.3% increase in January and a 0.1% decline in December. On an annual basis, the PPI increased 1.6%, “the largest rise since moving up 1.8% for the 12 months ended September 2023,” according to the BLS.

CITE: https://www.r2library.com/Resource

Here’s where the major benchmarks ended:

The market had a good Tuesday, with stocks climbing as investors await word from the Fed meeting today on any changes to interest rates. The bank is expected to keep rates the same for now, but could signal when (or how often) it’ll lower them later in the year. Meanwhile, Nordstrom shares surged following a report that the retailer’s founding family wants to take it private.
 

  • The S&P 500 index added 29.09 points (0.6%) to 5,178.51; the Dow Jones Industrial Average® ($DJI) gained 320.33 points (0.8%) to 39,110.76; the NASDAQ Composite® ($COMP) rose 63.34 points (0.40%) to 16,166.79.
  • The 10-year Treasury note yield (TNX) eased four basis points to just under 4.3%.
  • The CBOE Volatility Index® (VIX) lost 0.50 to 13.83. 

The energy sector was the top performer after crude oil prices notched multi-month highs ahead of weekly inventory data from the American Petroleum Institute. After a 2% rally to start the trading week, Brent Crude Oil (/BZ) futures, the global benchmark, added another 0.6% Tuesday.

Industrials, consumer discretionary, and utilities were among the other strong sectors. Communications, real estate, and materials finished modestly lower.

COMMENTS APPRECIATED

Thank You

***

***

Filed under: "Ask-an-Advisor", Breaking News, Drugs and Pharma, Ethics, Experts Invited, Financial Planning, Health Economics, Health Insurance, Healthcare Finance, Investing | Tagged: , , , , , , , , , , , , , , | Leave a comment »

DAILY UPDATE: “Medical Properties Trust” Tanks, FDA Approves Canadian Drugs and Medicare Advantage Health Plan [Part C] Patient Traps

Posted on January 7, 2024 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

***

SPONSOR: http://www.MarcinkoAssociates.com

***

Markets: Stocks climbed a bit on Friday as investors took in the news that the US added more jobs than expected in December, capping off an epic 2023 for the labor market. But it wasn’t a bright start to the year, as all three major averages broke a nine-week winning streak. Stock spotlight: The country’s largest hospital landlord, Medical Properties Trust, tanked after revealing that its biggest tenant was $50 million behind on rent.

***

Yesterday, the Food and Drug Administration (FDA) approved Florida’s request to import bargain medications from the country. It’s the first state to get permission from the agency to bring in medications from Canada under a law Congress passed 20 years ago to help Americans pay less for drugs. Florida officials say ordering cheaper drugs for conditions like HIV and diabetes from Canadian wholesalers will save Medicaid and other state programs $150 million over the first year.

CITE: https://www.r2library.com/Resource

***

Older Americans say they feel trapped in Medicare Advantage plans.

READ HERE: http://tinyurl.com/yck2yb8z

COMMENTS APPRECIATED

Thank You

***

***

Filed under: "Ask-an-Advisor", Alternative Investments, Drugs and Pharma, Financial Planning, Glossary Terms, Investing, Marcinko Associates, Touring with Marcinko | Tagged: , , , , , , , , , , , , , , , , , , , , , | Leave a comment »

DAILY UPDATE: Healthcare Artificial Intelligence Safety as the DJIA Sets Record

Posted on December 15, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Staff Reporters

***

SPONSOR: http://www.MarcinkoAssociates.com

***

Twenty-eight healthcare companies, including CVS Health , are signing U.S. President Joe Biden’s voluntary commitments aimed at ensuring the safe development of artificial intelligence (AI), a White House official said yesterday. The commitments by healthcare providers and payers follow those of 15 leading AI companies, including Google, OpenAI and OpenAI partner Microsoft to develop AI healthcare models responsibly.

***

***

Health insurance company Humana is being accused of allegedly wrongfully denying care to elderly patients, who are enrolled in Medicare Advantage Plans, using an augmented intelligence model “to override” physicians’ orders on “necessary care patients require,” according to a new lawsuit.

The lawsuit, filed by two Humana Medicare Advantage Plan customers on December th 12 in Kentucky, claims that Humana uses an AI model called nH Predict, and it allegedly has a high error rate. And allegedly, despite knowing that it’s inaccurate, the company still uses it.

Related: CVS, Kroger and Rite Aid face unsettling medical privacy concerns

***

***

Here is where the major benchmarks ended:

The S&P 500 index was up 12.46 points (0.3%) at 4,719.55; the Dow Jones Industrial Average was up 158.11 points (0.4%) at 37,248.35; the NASDAQ Composite® (COMP) was up 27.59 points (0.2%) at 14,761.56.

  • The 10-year Treasury note yield (TNX) was down about 11 basis points at 3.923%, falling under 4% for the first time since early August.
  • The CBOE® Volatility Index (VIX) was up 0.25 at 12.44.

Financial shares remained among the market’s strongest post-FOMC gainers, reflecting ideas that lower interest rates will boost profit margins for banks. Goldman Sachs (GS) rallied nearly 6%, the second-best gain among Dow companies, and hit a 23-month high. The KBW Bank Index (BKX), which includes major companies like Bank of America (BAC) and Citigroup (C) as well as several regional lenders, surged 5% to a nine-month high.

Also, the small-cap Russell 2000® Index (RUT) continued to outgain large-cap counterparts, rising 2.7% to a 4 ½-month high.

COMMENTS APPRECIATED

Refer a Colleague: MarcinkoAdvisors@msn.com

Your referral Count: 0

Thank You

***

***

Filed under: Alternative Investments, Ethics, Financial Planning, Funding Basics, Glossary Terms, Health Economics, Health Insurance, Health Law & Policy, Information Technology, Investing, Touring with Marcinko | Tagged: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment »

PROPOSED CHANGES: Medicare Advantage

Posted on November 7, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

JUST ANNOUNCED

By Staff Reporters

***

***

The Biden administration wants to make changes to private Medicare insurance plans that officials say will help seniors find plans that best suit their needs, promote access to behavioral health care and increase use of extra benefits such as fitness and dental plans.

PART C FRAUD: https://medicalexecutivepost.com/2023/10/24/podcast-medicare-advantage-part-c-fraud/

MEDICARE ADVANTAGE ALLEGATIONS: https://medicalexecutivepost.com/2022/09/06/medicare-part-c-advantage-plan-allegations-investigations/

COMMENTS APPRECIATED

Thank You

***

***

Filed under: "Doctors Only", Breaking News, Career Development, Managed Care, Risk Management | Tagged: , , , , , | Leave a comment »

MEDICARE ADVANTAGE PLANS: Part C Plans Down AS Cigna Pays Up?

Posted on October 3, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

Hospitals are Dropping Medicare Advantage [Part C] Plans – Left and Right

By Dr. David Edward Marcinko MBA

***

Hospitals Say Bye-Bye?

Medicare Advantage provides health coverage to more than half of the nation’s seniors, but a growing number of hospitals and health systems nationwide are pushing back and dropping the private plans altogether. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.

“It’s become a game of delay, deny and not pay,” Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.” Van Gorder said the health system is facing a loss of $75 million this year on the MA contracts, which will end December 31st for patients covered by UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Centene’s Health Net and a few more smaller carriers.

Source: Becker’s Hospital Review [9/27/23]

COMMENTS APPRECIATED

***

Cigna to Pay $172M Over Alleged Medicare Advantage Fraud

The Cigna Group will pay $172.3 million to resolve allegations that it violated the False Claims Act by submitting incorrect Medicare Advantage patient data to CMS to receive higher payments from the agency. The U.S. Attorney’s Office for the Eastern District of Pennsylvania alleged Sept. 30 that Cigna also falsely certified that the submitted data was accurate, failed to withdraw the “untruthful” data, and did not repay CMS.

Cigna will use $135.3 million from the settlement to resolve the allegations from the Justice Department. The remaining $37 million will resolve allegations related to unsupported diagnoses for Medicare Advantage enrollees that received in-home services from Cigna. As part of the settlement, Cigna has entered into a five-year accountability and auditing agreement with HHS’ Office of Inspector General, which will require company executives and board members to certify Cigna’s compliance moving forward. The payer must also conduct annual risk assessments and submit to independent risk adjustment audits.

Source: Jakob Emerson, Becker’s Payer Issues [10/2/23]

Thank You

***

***

Filed under: Ethics, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Managed Care, Marcinko Associates, Touring with Marcinko | Tagged: , , , , , , , , , , , , , | Leave a comment »

VALUATION: Medicare Advantage [Part C] Plans

Posted on June 15, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

By Health Capital Consultants, LLC

***

***

Valuation of MA Plans: Regulatory Environment

Healthcare provider organizations, including Medicare Advantage organizations (MAOs), face a range of federal and state legal and regulatory constraints, which affect their formation, operation, procedural coding and billing, and transactions.

CITE: https://www.r2library.com/Resource

This final installment of the three-part series on the valuation of Medicare Advantage (MA) plans will review the regulatory environment in which these plans operate. (Read more…) 

***

COMMENTS APPRECIATED

Thank You

***

***

Filed under: "Doctors Only", Accounting, Experts Invited, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Investing, Practice Management, Professional Liability | Tagged: , , , , , , , | Leave a comment »

PODCAST: Medicare Advantage Plan Over Payments

Posted on January 25, 2023 by Dr. David Edward Marcinko MBA MEd CMP™

A SYNOPSIS

By Eric Bricker

***

PODCAST: Government Overpayments to Medicare Advantage Plans are a major problem.

CMS pays Medicare Advantage Plans per member based on a risk score. The more chronic conditions the person has, the larger the payments CMS makes to the Medicare Advantage Plan.

Medicare Advantage Plans may be overexaggerating how sick their members are in order to increase their payments from CMS.

The Department of Justice is currently suing Cigna and Elevance (Anthem) for such over exaggerations.

However there is a deeper problem… CMS itself had performed its own audits, but has not done so in 10 years. CMS identified $650M in overpayments and did nothing about them.

When the Kaiser Family Foundation (KFF) requested information on the audits, CMS refused. KFF had to sue CMS to obtain the audit information and it took 3 years for KFF to win the case.

Perhaps it is incompetence on the part of CMS or perhaps CMS does not want to reveal the audits or do anything about them due to political pressure.

***

ORDER: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books& qid=1275315485&sr=1-4

***

COMMENTS APPRECIATED

Thank You

***

Filed under: "Advisors Only", "Doctors Only", Accounting, Ethics, Experts Invited, Health Insurance, Industry Indignation Index, Videos | Tagged: , , , , | 1 Comment »

MEDICARE: “Dis” Advantage Plan Marketing

Posted on November 2, 2022 by Dr. David Edward Marcinko MBA MEd CMP™

CMS Cracks Down on Medicare Advantage TV Marketing

Dr. David Edward Marcinko MBA

***

***

CMS is cracking down on deceptive marketing practices and will no longer allow Medicare Advantage or Part D prescription drug plans to advertise on television without agency approval first. The new policy is effective Jan. 1st and was discussed in an Oct. 19th memo from CMS to MA and Part D providers. The agency said it issued the new policy after reviewing thousands of beneficiary complaints regarding confusing, misleading or inaccurate information from plans — plan sponsors are also responsible for all marketing activities from brokers and third-party agencies.

“CMS has conducted so-called ‘secret shopping’ by calling numbers associated with television advertisements, mailings, newspaper advertisements and internet searches to monitor the experience beneficiaries have engaging these entities,” the agency wrote.

“Our secret shopping activities have discovered that some agents were not complying with current regulation and unduly pressuring beneficiaries, as well as failing to provide accurate or enough information to assist a beneficiary in making an informed enrollment decision.”

Source: Jakob Emerson, Becker’s Payer Issues [10/27/22]

***

OIG: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp

RELATED: https://medicalexecutivepost.com/2021/05/21/podcast-medicare-advantage-plans-insurance-company-goldmine

MORE: https://medicalexecutivepost.com/2022/04/29/probe-medicare-advantage-part-c-plans-deny-needed-care-to-tens-of-thousands-of-patients/

***

ORDER: https://www.amazon.com/Dictionary-Health-Insurance-Managed-Care/dp/0826149944/ref=sr_1_4?ie=UTF8&s=books&qid=1275315485&sr=1-4

***
COMMENTS APPRECIATED

Thank You

****

Filed under: "Ask-an-Advisor", Breaking News, Drugs and Pharma, Health Insurance, Health Law & Policy, iMBA, Inc., Industry Indignation Index, Managed Care, Touring with Marcinko | Tagged: , , , , | Leave a comment »

PODCAST: “Signify Health” Start-Up Risk Adjustments [Medicare Advantage Part C]

Posted on October 20, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

BY ERIC BRICKER MD

***


***
YOUR COMMENTS ARE APPRECIATED.

Thank You

***

Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

***

FINANCIAL PLANNING: https://www.routledge.com/Comprehensive-Financial-Planning-Strategies-for-Doctors-and-Advisors-Best/Marcinko-Hetico/p/book/9781482240283

***

***

Filed under: Ethics, Experts Invited, Health Economics, Health Insurance, Healthcare Finance, Investing, Videos | Tagged: , , , , , , , , , | 1 Comment »

PODCAST: The Four [4] Parts of Medicare

Posted on September 20, 2021 by Dr. David Edward Marcinko MBA MEd CMP™

UNDERSTAND AND KNOW THE DIFFERENCE: A, B C & D

CITE: https://www.r2library.com/Resource/Title/0826102549

BY MEDICARE – CMS

***

https://www.youtube.com/watch?v=9w4n5M18fto

***
YOUR COMMENTS ARE APPRECIATED.

Thank You

***

Filed under: Drugs and Pharma, Health Insurance, Health Law & Policy, Videos | Tagged: , , , , , , | 1 Comment »