Stories with related Professional Interests

Open Enrollment 2020: Be Prepared for Coverage Changes - 11/13/2019

You’re probably already aware that open enrollment for commercial health insurance plans, including those on the Affordable Care Act Exchanges, opened Nov. 1 and will run through Dec. 15. While some patients won’t make any changes to their coverage, others will make significant changes, including enrolling with a completely different health plan.


System Failure: Houston Practices Fight WellCare for Payment - 09/26/2019

Several Houston-area practices say a botched technology conversion by insurer WellCare after it acquired a Medicare Advantage plan led to prior authorization and network confusion, undue denials, and unpaid claims by the barrelful.


United Healthcare Cuts Consults - 09/04/2019

United Healthcare is eliminating payment for consults in two phases – one that took effect June 1 for certain services, and their complete elimination starting in October. The change is an effort to align with the Centers for Medicare & Medicaid Services policy that eliminated payment for most consults in 2010, but it’s going to make it more difficult for many specialists to get compensated for the extra time and work those services require.


Out in the Cold: Health Plan Blamed For Major Prompt-Pay Mess - 08/02/2019

Molina Healthcare of Texas isn’t the only insurer to give physicians prompt-pay problems, and it won’t be the last. Some of the practices trying to recover payments blame not just the health plan, but also the extended response time from the state regulator overseeing insurance products and conduct: the Texas Department of Insurance, which says it’s hiring staff and making other changes to improve that response.


TDI Fines Molina Healthcare $500,000 in Prompt-Pay Order - 04/30/2019

The Texas Department of Insurance (TDI) has fined an insurer whose inability to pay claims on time kept physicians waiting on millions of dollars. TDI dealt Molina Healthcare of Texas an administrative penalty of $500,000 – on top of almost $8 million combined that the insurer paid in penalties and interest to TDI, and to affected physicians and other health care providers.


Humana Revises Peer-to-Peer Review - 10/18/2018

Humana has tweaked its peer-to-peer review process for prior authorization requests, giving physicians contracted with its Medicare Advantage plans another opportunity for review before filing a claim.


TDI Fines Humana Over Inadequate Network - 10/12/2018

The Texas Department of Insurance has fined Humana $700,000 and ordered the insurer to take corrective steps for not having enough in-network anesthesiologists in Harris, Bexar, and Travis counties this year.


Payer Math Multiplies Recoupments - 07/10/2018

When does $187 equal nearly $13,000? When a payer projects overpayments. A weekly audio tip from the National Alliance of Medical Auditing Specialists cites a case in which illegible signatures forced a practice to refund almost $13,000.


Blue Cross to Put Off HMO Emergency Coverage Policy Until August - 06/27/2018

Blue Cross and Blue Shield of Texas will delay for 60 days a new HMO emergency care policy it had originally planned to begin on Monday, June 4.


Blue Cross Payment Cut on Tap for Some Diagnostic Services - 06/19/2018

Effective July 1, Blue Cross and Blue Shield of Texas will cut payments for certain diagnostic procedures. The cut will apply to diagnostic cardiovascular and ophthalmology procedures that are billed for the same patient on the same day.


Some Blue Cross Members Could Pay 100 Percent of ER Bill - 05/01/2018

The Texas Medical Association has reached out to Blue Cross and Blue Shield of Texas to obtain more details on a new HMO emergency care policy at BCBSTX unveiled this week.


TMA Lays Out Balance Billing Plan to Senate Panel - 04/27/2018

Just days after the House of Delegates adopted TMA's plan to preserve physicians' rights to bill for services and protect patients from surprise bills, TMA Council on Legislation Chair Ray Callas, MD, presented it to the Senate Committee on Business and Commerce.


TMA: CHIP Managed Care Plans Responsible for Out-of-Network Payments - 04/27/2018

Because federal law prohibits patients covered by the Children's Health Insurance Program (CHIP) from paying anything other than a copay, the state of Texas should require managed care organizations in CHIP to cover the costs for out-of-network physicians. That's the position TMA takes in a formal letter to the Texas Health and Human Services Commission.


Why Did I Get That Medical Bill? - 04/26/2018

A new epidemic has hit; call it "insurance illiteracy." Numerous studies (like this national research and this Texas study) show the public's growing lack of understanding of basic health insurance terms, such as "copay," "out-of-pocket expense," and "network." Reasons given for the problem include the addition of large numbers of people newly insured under the Affordable Care Act and the health insurance industry's growing array of confusing new products and cost-containment strategies.


STAR+PLUS Expansion News - 04/20/2018

People with intellectual and developmental disabilities covered by Medicaid will need to choose a STAR+PLUS health plan this summer for their doctor, hospital visits, and medications. Starting Sept. 1, these people will get their basic medical services through STAR+PLUS.


AMA Analyzes Potential Aetna-Humana, Anthem-Cigna Mergers - 04/17/2018

The combined impact of proposed mergers among four of the nation's largest health insurance companies would exceed federal antitrust guidelines designed to preserve competition in as many as 97 metropolitan areas within Texas and 16 other states, according to new special analyses of commercial health insurance markets issued by the American Medical Association.


New Guidance on Medicaid Prior Authorizations Related to Harvey Issued - 09/18/2017

The Texas Health and Human Services Commission (HHSC) has released new information and guidance on Medicaid prior authorizations as well as temporary electronic visit verification policies for physicians and other health care providers affected by Hurricane Harvey.


BCBSTX to Drop Individual PPO Plans - 06/23/2016

The Dallas Morning News reported last month that about 367,000 Texans "will lose their individual health insurance policies next year when BlueCross BlueShield of Texas stops offering its Blue Choice PPO [preferred provider organization] plans." The insurer said it paid out $400 million more in claims in 2014 than it collected in premiums.


TDI FAQs Address 90-Day Grace Period, Prompt Pay - 05/31/2016

The Texas Department of Insurance (TDI) has updated its FAQs for Health Carriers to include information about the federal 90-day grace period granted to patients with subsidized ACA health insurance marketplace coverage and about prompt payment of claims.


Medicare Ordering/Referring Edits Extended to Certifying Physicians - 05/13/2016

Beginning today, July 1, the certifying physician reported on a Medicare home health agency claim must be enrolled in Medicare. If not, the claim will be denied under Medicare's ordering and referring denial edits.


STAR+PLUS Expands to Rural Areas - 05/13/2016

On Sept. 1, the STAR+PLUS Medicaid managed care program expanded to 164 rural counties not currently participating in the model. The expansion requires elderly patients eligible for Medicaid long-term services and supports (LTCSS) and adult patients with disabilities to enroll in a STAR+PLUS plan. Children with disabilities may enroll voluntarily.


Sunshine Act Physician Registration Process Has Begun - 05/12/2016

Later this year under the Physician Payments Sunshine Act, the Centers for Medicare & Medicaid Services will make public physician payments reported by manufacturers of drugs, medical devices, and biologicals that participate in federal health care programs.