Weslaco ISD vs Aetna – News Reporter Seeks Update

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Texas news reporter seeks update on Weslaco ISD vs Aetna lawsuit: http://bloximages.newyork1.vip.townnews.com/galvestondailynews.com/content/tncms/assets/v3/editorial/6/08/6080d8ce-b862-11e2-afc1-0019bb30f31a/518b28d375654.pdf.pdf

See original pleading: http://blog.riskmanagers.us/wp-content/uploads/2011/06/Weslaco-vs-Aetna.pdf

Editor’s Note: From our perspective, the most interesting information coming out of this cause of action is the Aetna ASO contract provisions regarding earned fees derived from PPO discounts. Working the spread between charge master rates and managed care negotiated allowed charges can be lucrative. For example, a 9.5% of “savings” fee can add up quick. Hospital charge masters are third party intermediaries best friends – http://blog.riskmanagers.us/?p=11527

Also see http://blog.riskmanagers.us/?p=6040, Weslaco vs Aetna

 

BCBS Pays 100% Medicare Allowable For Non-Network Providers

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What is Blue Cross’ allowed amount for nonparticipating providers? For physicians, clinics, Ambulatory Surgery Centers (ASC) services, and/or facility services by nonparticipating providers, with some exceptions, the allowed amount for most plans is 100% of the Medicare Allowed Charge that is published at the United States website for Centers for Medicare and Medicaid Services (CMS): http://www.cms.gov/ ExternalLink .”

If Blue Cross pays 100% of Medicare allowable for non-network providers, what do they pay for network providers? Do they pay more, or less? Clue – http://blog.riskmanagers.us/?p=13247

http://www.bluecrossmn.com/Page/mn/en_US/nonparticipating-providers

Editor’s Note: From all indications, the BUCA’s pay out-of-network providers anywhere from 100% – 105% of Medicare allowable.

Medicare To Pay Flat Rate For Clinic Visits

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Despite criticism from hospitals and doctors, the CMS intends to pay flat rates for Medicare visits to outpatient clinics instead of payments that vary with the severity of the patient’s condition. However, the agency decided not to enact a similar policy for emergency-room visits—at least for the time being.
The 1,200-page outpatient prospective payment system rule for 2014, posted the Wednesday afternoon before Thanksgiving, says the agency is changing its longstanding approach to paying for clinic visits because of a widespread concern that the old system encourages upcoding.

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