Blog

»  Posts By   2016 

Medicare Launches New Comprehensive Care for Joint Replacement Bundled Payment Model

As part of the new Alternative Payment Model (APM) intended to improve the patient experience, increase the population’s health, and reduce per capita costs for certain medical procedures, Medicare has launched the Comprehensive Care for Joint Replacement (CJR) Bundled Payment Model. The program went into effect in April 2016 and will continue for the next 5 years. The CJR is a bundled payment program that focuses on hospitals where joint...

CMS Announces New Comprehensive Primary Care Plus (CPC+) Payment Model for Primary Care Practices

The Centers for Medicare & Medicaid Services (CMS) recently announced Comprehensive Primary Care Plus (CPC+), the latest payment model for primary care practices. CPC+ is a multi-payor risk and incentive based payment model that makes notable changes to how primary care practices are paid in order to improve the quality of care and decrease excess healthcare utilization. Based on lessons learned from the Comprehensive Primary Care model, CMS claims this new...

What Providers Need to Know about MACRA’s Value-Based Tracks: Merit-based Incentive Payment Systems (MIPs) and Alternative Payment Models (APMs)

Over the past few years, the Centers for Medicare & Medicaid Services (CMS) has been looking to find new and innovative ways to reimburse providers who provide care to Medicare beneficiaries. In April 2015, Medicare Access and CHIP Reauthorization Act (MACRA), a new and alternative payment method law that revamps fee-for-service payment, was signed in to law by President Obama. MACRA is proposed to change the way Medicare pays clinicians and...

Humana’s Widespread Auditing of Pharmacies for Authorized Off-Label Prescribing of Transmucosal Immediate-Release Fentanyl (TIRF) Drug Products

According to the 2015 Form 10-K filed by the drug manufacturer Insys Therapeutics, Inc., Humana began sending letters to its participating pharmacy providers in January 2016 "indicating that as a result of a CMS audit, Humana was initiating a deletion of certain [Prescription Drug Events] related to Subsys which will result in a reversal and recovery of identified claims paid to certain pharmacies." Subsys and other TIRF drug products are subject...

Termination ALERT: Prime Therapeutics Undertakes Efforts to Terminate Pharmacies Pursuant to “Enhanced” Network Participation Criteria

As of August 30th, pharmacies across the nation have begun receiving form termination letters from Prime Therapeutics stating that Prime Therapeutics has made certain "enhancements" to its network participation criteria, resulting in the termination of many compounding pharmacies.  These pharmacies are being notified of their resultant termination from Prime's network due to the fact that processing compound drug claims in excess of 10% fails to comport with these "enhancements." It...