Tag Archives: network adequacy

Exaggerated Diagnosis Codes and Inadequate Provider Networks: Allegations of Medicare Advantage Fraud Settled for $32.5 Million

Photo of Kevin BradberryBy Kevin Bradberry on Posted in Uncategorized
The latest settlement involving Medicare Advantage (MA) organizations highlights not only the government’s continuing enforcement focus on Medicare Part C but also the vulnerabilities inherent in that program. In United States ex rel. Sewell v. Freedom Health, Inc. et al., two Florida-based MA organizations – Freedom Health and Optimum HealthCare – agreed to pay $32.5 … Continue Reading

Market Stabilization: To Be or Not to Be?

By Susan Feigin Harris on Posted in Uncategorized
The Centers for Medicare and Medicaid Services (CMS) published a Final Rule intended to stabilize the individual and small group insurance markets on April 18, 2017. Reflecting the urgent need to address the uncertainty afflicting the markets, CMS advanced the rule from proposed to final form in just two short months despite receiving more than … Continue Reading

Reducing the Regulatory Stranglehold on Federally Facilitated Exchanges: Will It Work?

By Susan Feigin Harris on Posted in Uncategorized
The Centers for Medicare and Medicaid Services (CMS) recently issued a proposed rule aimed at improving the individual and small group markets that have been plagued with instability as issuers continue exiting the Exchanges. While the proposed rule is primarily focused on the Federally-facilitated Exchanges (FFEs), CMS is encouraging state-based Exchanges to adopt similar policies. … Continue Reading

What Does the CMS Notice of Benefit and Payment Parameters Mean for Providers?

By Susan Feigin Harris on Posted in Uncategorized
The Centers for Medicare & Medicaid Services (CMS) recently issued its proposed Notice of Benefit and Payment Parameters for 2018 (Proposed Rule) a couple of months earlier than in the past – one of the administration’s many actions aimed at setting the tone going into the election and the coming year. The release of the Proposed … Continue Reading

The 2017 Exchange Regulations: Network Adequacy Challenges Remain

By Susan Feigin Harris and Summer D. Swallow on Posted in Uncategorized
The impact of these rules will be felt widely among the provider community as it struggles to face increasing pressures resulting from the plans’ continually narrowing networks The Centers for Medicare and Medicaid Services (CMS) recently issued the final 2017 Benefit and Payment Parameters Rule (Final Rule) and concurrently released a final 2017 Letter to … Continue Reading
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