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Medical Director – Medicaid

Medical Director – Medicaid (Remote)

Job Locations

Remote

Job ID

 
 

2020-10798

 
 

Category

 
 

Product Development

Overview

As the Medicaid Medical Director, Medicaid you will to be a part of our innovative product solution development team. You will assist in crafting products tailored for individuals covered by Medicaid to afford them the opportunity to successfully live, heal and age at home. You will be an integral part of internal and external client meetings, sales opportunities, product implementation and quality processes. 

 
 

Responsibilities

  • Serve as the Medicaid clinical lead for all quality, clinical, utilization management, and policies for Medicaid and LTSS programs.
  • Provide leadership and coordination for the development and implementation of a cohesive approach to measuring and promoting quality, and lead priority-setting process for clinical quality improvement for Medicaid and LTSS programs.
  • Provide clinical support and expertise focusing on Medicaid and LTSS for program development.
  • Participate in leadership, stakeholder and Advisory Board meetings
  • Build and maintain effective working relationships with cross-functional leaders and teams in order to identify, explore, present and implement Medicaid program opportunities.

Qualifications

  • MD or DO with an active and unencumbered medical license.
  • 5 years’ plus  experience in an area of relevant clinical practice
  • 5 years’ plus experience with a Medicaid health plan, or a State Medicaid Agency. LTSS population experience preferred.
  • Excellent verbal and written communication skills and be able to communicate effectively in large and small group settings.
  • Medicaid thought leader with market intelligence.
  • Experience with Medicaid and LTSS program utilization management, clinical management, program development, or program evaluation—either with a health plan, Medicaid Managed Care organization or state Medicaid Agency
  • Ability to develop, collaborate with, and support relationships with key stakeholders internally and externally (client CMOs and Medicaid Associations)

 
 

 
 

 
 

 
 

 
 

Clipped from: https://careers-carecentrix.icims.com/jobs/10798/job?utm_source=indeed_integration&iis=Job+Board&iisn=Indeed&indeed-apply-token=73a2d2b2a8d6d5c0a62696875eaebd669103652d3f0c2cd5445d3e66b1592b0f&mode=job&iis=Indeed&iisn=Indeed.com&mobile=false&width=1479&height=500&bga=true&needsRedirect=false&jan1offset=-360&jun1offset=-300

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MEDICAID PROGRAM MANAGER 1–A

 
 

Supplemental Information

Job Number: MVA/SAG/1961
 
 This position is located within the Louisiana Department of Health l Medical Vendor Administration l Program Integrity  l  EBR Parish.
 
 Cost Center: 0305-7104
 Position Number(s): 50550788
 
This vacancy is being announced as a Classified position and may be filled either as a Probationary Appointment, Job Appointment or Promotional Appointment.  

(Job Appointments are Temporary Appointments up to 48 months)

 
****REVIEW YOUR APPLICATION TO MAKE SURE IT IS CURRENT. Failure to provide your qualifying work experience may result in your application not being considered.****
 
 
There is no guarantee that everyone who applies to this posting will be interview.  The hiring supervisor/manager has 90 days from the closing date of the announcement to make a hiring decision.  Specific information about this job will be provided to you in the interview process, should you be selected.

No Civil Service test score is required in order to be considered for this vacancy.  
 
To apply for this vacancy, click on the “Apply” link above and complete an electronic application, which can be used for this vacancy as well as future job opportunities. Applicants are responsible for checking the status of their application to determine where they are in the recruitment process. Further status message information is located under the Information section of the Current Job Opportunities page.
 
*Resumes WILL NOT be accepted in lieu of completed education and experience sections on your application. Applications may be rejected if incomplete.*
 
For further information about this vacancy contact:
Sanaretha Gray @ Sanaretha.Gray@la.gov    
LDH/HUMAN RESOURCES
P.O. BOX 4818 BATON ROUGE, LA 70821
225 342-6477
 

 

Qualifications

MINIMUM QUALIFICATIONS:

A baccalaureate degree plus four years of professional experience in administrative services, economics, public health, public relations, statistical analysis, social services, or health services.

 
 

SUBSTITUTIONS:
Six years of full-time work experience in any field may be substituted for the required baccalaureate degree.

Candidates without a baccalaureate degree may combine work experience and college credit to substitute for the baccalaureate degree as follows:


A maximum of 120 semester hours may be combined with experience to substitute for the baccalaureate degree.


30 to 59 semester hours credit will substitute for one year of experience towards the baccalaureate degree.

60 to 89 semester hours credit will substitute for two years of experience towards the baccalaureate degree.
90 to 119 semester hours credit will substitute for three years of experience towards the baccalaureate degree.
120 or more semester hours credit will substitute for four years of experience towards the baccalaureate degree.

College credit earned without obtaining a baccalaureate degree may be substituted for a maximum of four years full-time work experience towards the baccalaureate degree. Candidates with 120 or more semester hours of credit, but without a degree, must also have at least two years of full-time work experience tosubstitute for the baccalaureate degree.

 
 

Graduate training with eighteen semester hours in one or any combination of the following fields will substitute for a maximum of one year of the required experience on the basis of thirty semester hours for one year of experience: public health; public relations; counseling; social work; psychology; rehabilitation services; economics; statistics; experimental/applied statistics; business, public, or health administration.

 
 

A master’s degree in the above fields will substitute for one year of the required experience.

 
 

A Juris Doctorate will substitute for one year of the required experience.

 
 

Graduate training with less than a Ph.D. will substitute for a maximum of one year of the required experience.

 
 

A Ph.D. in the above fields will substitute for two years of the required experience.

 
 

Advanced degrees will substitute for a maximum of two years of the required experience.

 
 

NOTE:
Any college hours or degree must be from a school accredited by one of the following regional accrediting bodies: the Middle States Commission on Higher Education; the New England Association of Schools and Colleges; the Higher Learning Commission; the Northwest Commission on Colleges and Universities; the Southern Association of Colleges and Schools; and the Western Association of Schools and Colleges.

Job Concepts

Function of Work:
To administer small and less complex statewide Medicaid program(s).

Level of Work:

Program Manager.

Supervision Received:

Broad from a higher-level manager/administrator.

Supervision Exercised:

May provide functional supervision in accordance with the Civil Service Allocation Criteria Memo.

Location of Work:

Department of Health and Hospitals.

Job Distinctions:

Differs from Medicaid Program Monitor by responsibility for administering small and less complex statewide program(s).

Differs from Medicaid Program Manager 1-B by the absence of supervisory responsibility.


Differs from Medicaid Program Manager 2 by the absence of responsibility for administering medium size and moderately complex statewide program(s).

Examples of Work

Supervises the auditing of eligibility enrollment of all Medicaid programs statewide.

Reviews work of eligibility review staff for quality assurance.


Plans, coordinates, and controls small or less complex statewide program(s).


Plans, develops, implements and monitors comprehensive Medicaid program policies.


Conducts and directs studies/special projects pertaining to the programs assigned.


Analyzes the impact of federal, state, and local legislation; advises agency officials; prepares position statements; presents testimony at hearings; writes legislation.


Reviews and analyzes complex data and system reports to ensure compliance with program regulations.


Administers the day-to-day operational functions of the Medicaid fee for service programs. Assures that program policy and procedures are properly applies in accordance with federal and state laws and regulations.


Develops and writes agency rules and regulations governing the administration of all supervised Medicaid programs and submit them for publishing in the official state publication in accordance with the requirements of the Administrative Procedures Act.


Implements Medicaid regulations directing provider participation standards and recipient benefits. Analyzes multi-mullion dollar Medicaid claim data and project the fiscal impact for budget forecasting.


Identifies, verifies and analyzes the various revenue sources for the program(s). Determines and/or confirms match requirements. Monitors availability of revenue sources and promptly identifies existing or potential financing problems.

Benefits

Louisiana State Government represents a wide variety of career options and offers an outstanding opportunity to “make a difference” through public service. With an array of career opportunities in every major metropolitan center and in many rural areas, state employment provides an outstanding option to begin or continue your career. As a state employee, you will earn competitive pay, choose from a variety of benefits and have access to a great professional development program.

Flexible Working Arrangements – The flexibility of our system allows agencies to implement flexible working arrangements through the use of alternative work schedules, telecommuting and other flexibilities. These arrangements vary between hiring agencies.

Professional Development – The Comprehensive Public Training Program (CPTP) is the state-funded training program for state employees. Through CPTP, agencies are offered management development and supervisory training, and general application classes on topics as diverse as writing skills and computer software usage.

Insurance Coverage – Employees can choose one of several health insurance programs ranging from an HMO to the State’s own Group Benefits Insurance program. The State of Louisiana pays a portion of the cost for group health and life insurance. Dental and vision coverage are also available. More information can be found at www.groupbenefits.org.

Deferred Compensation – As a supplemental retirement savings plan for employees, the State offers a Deferred Compensation Plan for tax deferred savings.

Holidays and Leave – State employees receive the following paid holidays each year: New Year’s Day, Martin Luther King, Jr. Day, Mardi Gras, Good Friday, Memorial Day, Independence Day, Labor Day, Veteran’s Day, Thanksgiving Day and Christmas Day. Additional holidays may be proclaimed by the Governor. State employees earn sick and annual leave which can be accumulated and saved for future use. Your accrual rate increases as your years of service increase.

Retirement – State of Louisiana employees are eligible to participate in various retirement systems (based on the type of appointment and agency for which an employee works).  These retirement systems provide retirement allowances and other benefits for state officers and employees and their beneficiaries. State retirement systems may include (but are not limited to): Louisiana State Employees Retirement System (www.lasersonline.org), Teacher’s Retirement System of Louisiana (www.trsl.org), Louisiana School Employees’ Retirement System (www.lsers.net), among others. LASERS has provided this video to give you more detailed information about their system.

Clipped from: https://www.governmentjobs.com/careers/louisiana/jobs/2949308/medicaid-program-manager-1-a

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Provider Clinical Liaison – North Carolina Medicaid in Cary, NC – Anthem

 
 

Description

SHIFT: Day Job

SCHEDULE: Full-time


 

Your Talent. Our Vision. At Healthy Blue, a strategic alliance of Blue Cross NC and Amerigroup, an Anthem Inc. companyit’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America’s leading health benefits companies and a Fortune Top 50 Company

This position may be remote within NC and will be responsible for overseeing a designated region of NC. Home office location: 11000 Weston Parkway, Cary, NC. Candidates must reside in the state of NC or neighboring states. Currently, this position is remote due to COVID. Once we resume all standard operations, travel time for this position will be as indicated under the Requirements section. 

The Provider Clinical Liaison supports primary care groups in Advanced Medical Home population health activities. This position serves a key role in Healthy Blue’s geographically organized provider support. The Clinical Liaison is responsible for managing quality and medical expense goal metrics for primary care groups by assisting in connecting high risk members and those having HEDIS gaps to their medical homes, to establish care plans that improve health outcomes. 

Primary duties include:

  • Use Healthy Blue databases and tools, including risk adjustment tools to identify opportunities for improvement in quality and costs for members in assigned practices
  • Develop an operational plan for each medical practice to deploy office personnel and coordinate with Healthy Blue resources to optimize performance on targeted quality measures and to improve clinical and cost outcomes for members identified to have high clinical risk
  • Coordinate scheduling of high risk members and those having HEDIS gaps for appointments
  • Communicate with medical office personnel about identified gaps in care that will be apparent to the practitioner at the patient encounter
  • Meet with physicians and other clinical personnel to problem solve and develop engagement plans for high risk members
  • Work with practitioners and office staff to improve documentation of diagnoses, including specific manifestations, facilitate access of members to Healthy Blue case management, population health, and behavioral health programs as indicated, and help coordinate services provided by practice and Healthy Blue personnel
  • Serve as the subject matter expert for primary care practices on all Healthy Blue clinically focused program
  • Conduct periodic meetings with each practice to track progress towards implementing the project plan and attaining goals established in the engagement contract
  • Support the Healthy Blue Provider Collaboration Lead in organizing and implementing support to achieve targeted revenue, medical expense, and quality goals for the assigned region 
  • Assures compliance to practice guideline, delegation and continuity and coordination of care standards 
  • Provides oversight to assure accurate and complete quantitative analysis of clinical data and presentation of results. 

Qualifications

Requires: 

  • BA/BS in Nursing 
  • Minimum 5 years of clinical experience 
  • Demonstrated commitment to clinical quality improvement  
  • Unrestricted RN license in the state of North Carolina
  • This position requires field work, visiting providers, approximately 75% of the time.

 
 

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2019 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran. 

 
 

Clipped from: https://anthemcareers.ttcportals.com/jobs/6131116-provider-clinical-liaison-north-carolina-medicaid?tm_job=PS43677&tm_event=view&tm_company=2522&bid=370

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Director Network Management (Contracting) in Nashville, TN – Anthem

 
 

Description

SHIFT: Day Job

SCHEDULE: Full-time


 

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

 
 

This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America’s leading health care companies and a Fortune Top 50 Company.

 
 

Director – Network Management (Contracting)

 
 

 
 

Responsible for network development and provider reimbursement for the Statewide  Health Services Area. Primary duties may include, but are not limited to: Oversees contracting and maintenance of all facilities including hospitals, surgery centers, etc. Oversees the development, maintenance and reconciliation of physician risk contracts and capitated arrangements. Attracts, develops and manages key contracting staff. Develops innovative strategies to maintain a cost effective network with adequate access and positive working relationships with providers. Hires, trains, coaches, counsels, and evaluates performance of direct reports. 

Qualifications

  • BS/BA degree in business administration or related healthcare field
  • 8-10 years’ healthcare operations, finance, underwriting, actuary, network development and sales experience; or any combination of education and experience, which would provide an equivalent background.

Preferences:

  • CPA or MBA 
  • Comprehensive knowledge and understanding of managed care principles and practices, experience in fee for service, value based payment models, hospital, complex health systems, physician and ancillary provider types
  • Demonstrated track record of success in negotiating with providers including preparation and design of the negotiation as well as execution
  • Proven ability to prepare and present managed care strategies
  • Demonstrated analytical skills, including financial modeling and reimbursement technologies
  • Knowledge of payer and hospital/physician managed care operations
  • Demonstrated knowledge of Federal and State Regulations, including Medicare, Medicaid

 
 

Clipped from: https://anthemcareers.ttcportals.com/jobs/6034009-director-network-management-contracting

 
 

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Worth the Read?: The Path Forward (UnitedHealth Group, September 2020)

This article is part of our whitepaper review series called Worth the Read?, where we boil down HHS industry whitepapers. We believe most whitepapers have little value beyond marketing the producer’s services, and we want to save you time in sorting through what is or isn’t Worth the Read.

Whitepaper Reviewed

UnitedHealth Group: The Path Forward to a Next-Generation Health System

A four-page quick read.

The Gist

Cynical view- A health insurer wants more people to have health insurance. Idealist view- A health insurer in a unique position to have broad impact is putting forth new ideas in advance of significant federal change under an incoming Biden administration.

Key Points

UHG breaks up its overall vision into 4 major objectives:

  1. Achieve universal coverage
  2. Improve health care affordability
  3. Enhance the healthcare experience
  4. Drive better health outcomes

Overall Assessment of Value – WORTH THE READ

Overall this whitepaper is strong on specifics across both Medicaid and exchange verticals. There is solid quantification of multiple pieces of their objectives. And to be honest its pretty interesting to have a behemoth the size of UHG telegraph this type of strategy.

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Dickson Co. Woman Charged with TennCare Fraud

MM Curator summary

 
 

TN mother falsely reported she had custody of her so that she could get Medicaid benefits. $9,000.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

 
 

NASHVILLE, Tenn. – A Dickson County woman is charged with TennCare fraud and theft of services for allegedly falsely reporting that she had custody of her son in order to obtain TennCare benefits for herself.

The Office of Inspector General (OIG), in a joint effort with the Dickson County Sheriff’s Office, today announced the arrest of 31-year old Megan Hood of Dickson. Both charges against her are class D felonies.

Investigators allege that Hood falsely reported that she had custody of her son in order to receive TennCare benefits for herself.  As a result, the state says TennCare paid more than $9,000 in fees and claims on her behalf.  

“Lying in order to wrongfully receive TennCare benefits will not be tolerated,” Inspector General Kim Harmon said. “Our agency diligently investigates these situations in order to preserve Tennessee’s Medicaid resources for those truly deserving.”

The case is being prosecuted by District Attorney General Ray Crouch of Dickson County.

The OIG, which is separate from TennCare, began full operation in February 2005 and has investigated more than 5,760 criminal cases leading to more than $10.8 million being repaid to TennCare, with a total estimated cost avoidance of more than $163.6 million for TennCare, according to latest figures. To date, 3,100 people have been charged with TennCare fraud.

Through the OIG Cash for Tips Program established by the Legislature, Tennesseans can get cash rewards for TennCare fraud tips that lead to convictions.  Anyone can report suspected TennCare fraud by calling 1-800-433-3982, toll-free or by logging on to www.tn.gov/oig/ and following the prompts that read “Report TennCare Fraud.”

 
 

Clipped from: https://www.tn.gov/finance/news/2021/1/5/dickson-co–woman-charged-with-tenncare-fraud.html

 
 

 
 

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The U.S. and Tennessee resolve claims worth $1.72 Million

MM Curator summary

 
 

A group of TN doctors got paid by Medicare and TN Medicaid for an implantable acupuncture device that was not covered.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

 
 

The exterior of the United States Department of Justice on Feb 16, 2018 in Washington, D.C.

ALEX EDELMAN/AFP/Getty Images

NASHVILLE (WSMV) – Don Cochran, U.S. Attorney for the Middle District of Tennessee, and Herbert Slatery III, Attorney General for the State of Tennessee, announced today that they have settled claims between three providers for false liability under the False Claims Act for the alleged improper billing for electro-acupuncture using a peri-auricular stimulation device known as “P-Stim” that does not qualify for reimbursement under Medicare or TennCare. 

James P. Anderson, M.D. (“Dr. Anderson”), owner of Affiliated Neurologists, PLC; Charles F. Spencer, D.C., owner of Total Family Physicians Center PLLC d/b/a Total Family Health & Wellness (“Total Family”); and Mitchell P. Shea, D.C., owner of Chiro2Med of Tennessee P.C. (“Chiro2Med”) agreed to pay a combined $1.72 million to resolve liability. 

P-Stim is an electro-acupuncture device that, pursuant to manufacturer’s instructions, is affixed behind a patient’s ear using an adhesive.

Once activated, the device then provides intermittent stimulation by electrical pulses.

Medicare and TennCare do not reimburse for such acupuncture devices, nor do Medicare and TennCare reimburse for P-Stim as a neurostimulator or as implantation of neurostimulator electrodes. 

From May 2016 through November 2018, Dr. Anderson, Total Family, and Chiro2Med billed for, and were reimbursed by the United States for acupuncture using P-Stim devices under HCPCS Code L8679, which instead requires implantation of a neurostimulator with anesthesia in a surgical setting by a physician, typically a surgeon.  Dr. Anderson, Total Family, and Chiro2Med separately billed for, and were reimbursed by, Medicare and/or TennCare for these devices over a two year period.  

On June 10, 2020, Tennessee brought suit in the Chancery Court of Davidson County against Dr. Anderson under the Tennessee Medicaid False Claims Act for the false claims he submitted to TennCare.

Under the terms of the settlement, Dr. Anderson agreed to pay $1 million to the United States and Tennessee over five years.

Dr. Anderson also agreed to enter into an Integrity Agreement with the Office of Inspector General of the U.S. Department of Health and Human Services that will require regular monitoring of its billing practices for a period of three years.

Dr. Spencer and Total Family agreed to pay the United States $700,000 over five years.

Dr. Shea and Chiro2Med agreed to pay the United States $20,000 over five years.

“These settlements are part of a nationwide effort to hold accountable those providers who were paid improperly for non-reimbursable acupuncture under the guise of a surgically implanted neurostimulator,” said U.S. Attorney Cochran.  “Working closely with our partners at CMS’s Center for Program Integrity, the Department of Health and Human Services Office of the Inspector General, our sister U.S. Attorney’s Offices, and the Tennessee Attorney General’s Office, we were able to identify those who profited from the submission of these false claims and negotiate resolutions that resulted in a significant recovery of taxpayer dollars.”

“This Office will not tolerate medical device fraud in Tennessee, whether it is the P-Stim as in these cases, or any type of fraud,” said General Slatery.

These cases were handled by the United States Attorney’s Office for the Middle District of Tennessee and the Tennessee Attorney General’s Office, Medicaid Fraud and Integrity Division, with assistance from the Tennessee Bureau of Investigation Medicaid Fraud Control Unit and the Department of Health and Human Services, Office of Inspector General.  Assistant U.S. Attorney Kara F. Sweet represented the United States.  Deputy Attorney General Tony Hullender represented Tennessee.

 
 

Clipped from: https://www.wsmv.com/news/the-u-s-and-tennessee-resolve-claims-worth-1-72-million/article_5155c642-4ed3-11eb-8c84-03fb1e524dbc.html?block_id=998344

 
 

 
 

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AG’s Office: Gallup agency owner pleads guilty to Medicaid fraud

MM Curator summary

 
 

A New Mexico personal care agency owner falsified billings for her employees.

 
 

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

 
 

 
 

SANTA FE, N.M. (KRQE) – The New Mexico Office of the Attorney General reports that it has secured a guilty plea from Lolita Begay-Yazzie to one count of fraud in excess of $20,000 and one count of failure to retain documents for defrauding New Mexico’s Medicaid program of over $40,000. According to the Office of the Attorney General, Begay-Yazzie owned and operated a personal care agency in Gallup, New Mexico.

“Medicaid ensures that almost half of all New Mexicans have access to healthcare, and we must do all we can to protect these resources that are so vital to our families,” said Attorney General Hector Balderas. “We will continue to hold anyone who tries to steal these critical healthcare resources accountable.”


In a press release, the Office of the Attorney General states that Begay-Yazzie billed New Mexico Medicaid as if her employees were providing care services in excess of 24-hours a day. Begay-Yazzie is also accused of overbilling Medicaid for more services than each patient required to meet their needs according to their care plan.

The AG’s Office says that Begay-Yazzie made withdrawals at ATMs in casinos in excess of $85,000 from the personal care agency account. The court has ordered a pre-sentence report and is said to hold a sentencing hearing in the coming months.

According to the terms of the plea, Begay-Yazzie is facing up to five years of incarceration and will be excluded from providing any Medicaid services in the future. The Office of the Attorney General’s Medicaid Fraud Control Unit investigated and prosecuted this case.

Clipped from: https://www.krqe.com/news/crime/ag-gallup-agency-owner-pleads-guilty-to-medicaid-fraud/

 
 

 
 

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CMS issues guidance for state Medicaid SDOH programs

MM Curator summary

CMS guidance on priority focus areas for SDH efforts in Medicaid is now out.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

CMS issued a new guidance for state officials looking to roll out social determinants of health strategies for Medicaid and Children’s Health Insurance Program members.

The guidance, released Jan. 7, focuses on how state Medicaid directors can use flexibilities under federal law to design programs that decrease healthcare spending and improve outcomes through addressing social, environmental and economic factors.

CMS’ guidance focuses on housing projects, nonmedical transportation, meal delivery, education and employment support, among others. 

View the full guidance here.



Clipped from: https://www.beckershospitalreview.com/payer-issues/cms-issues-guidance-for-state-medicaid-sdoh-programs.html


 

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Appeals Court Upholds Trump Rule Requiring Hospitals to Show Prices Upfront

MM Curator summary

Despite industry opposition, hospitals will now have to report the prices they accept from insurers as payment.

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

The U.S. Court of Appeals for the D.C. Circuit on Tuesday upheld a Trump administration rule that requires hospitals to disclose the prices they negotiate with insurers for a range of health tests and procedures.

The 2-0 decision by the appeals court means that American patients will have access to hospital pricing information starting on Jan. 1, 2021, helping them find the lowest costs and the highest quality of care when deciding on treatment.

“This transformative hospital price transparency rule has been fought at every step by the swamp and defenders of the status quo,” White House Press Secretary Kayleigh McEnany said in a statement.

“Today’s ruling should reassure the American people that President Donald J. Trump refuses to bow to the influence of special interests who would prefer to keep patients in the dark. This initiative is just one in a series of rules that will bring unprecedented price transparency to all elements of healthcare,” she added.

The Centers for Medicare & Medicaid Services (CMS) issued the transparency rules in November 2019, calling on hospitals to make public the often-secret rates that they negotiate with insurance companies for all services, drugs, and supplies. The Department of Health and Human Services (HHS) said in a statement at the time that hospitals must make public all standard hospital charges in a single data file.

The moves came as a result of Trump’s signing of an executive order in June 2019 over price transparency.

Hospitals, insurer organizations, and advocacy groups objected to the rules, and said that the Trump administration did not have authority to require the disclosures, which they held to be trade secrets. The hospitals also disputed that the policy would benefit consumers and lead to lower costs, arguing that compliance would instead be too burdensome and interfere with their care for patients.

The finalization of the rule prompted the American Hospital Association (AHA) to file a legal challenge. They argued that the White House didn’t have the authority to make the rule and in doing so had violated the First Amendment in its creation, and had acted in an “arbitrary and capricious” manner.

A federal judge ruled on June 23 that the Trump administration rules were legal. But the groups appealed on Oct. 15.

In the appeal, the groups said that the price transparency rules would pose a “herculean” and costly task of compiling health care costs, while reducing competition and causing confusion about patients’ out-of-pocket expenses.

Circuit Judge David Tatel, however, said concerns about the burdens “miss the mark,” and pointed to HHS Secretary Alex Azar’s findings that greater disclosures would benefit the “vast majority” of consumers and likely result in lower—not higher—prices.

“The Secretary weighed the rule’s costs and benefits and made a reasonable judgment that the benefits of easing the burden for consumers justified the added burdens imposed on hospitals,” Tatel wrote.

The latest decision upholds the June 23 ruling by U.S. District Judge Carl Nichols.

Melinda Hatton, the AHA’s general counsel, said the group was disappointed and hopes that a potential Biden administration would revise the rule and exercise “enforcement discretion” until the CCP (Chinese Communist Party) virus pandemic runs its course.

On Twitter, Azar praised the decision. “Big win for American patients today. The DC Circuit ruling is another major victory for President Trump’s transformative healthcare agenda. Starting January 1, Americans will have access to the actual prices paid for the most common hospital services,” he wrote.

The U.S. Chamber of Commerce supported the hospital groups, saying the rule could cause hospitals to demand higher prices for their services if they saw other hospitals charging more.

The case is American Hospital Association et al v. Azar, D.C. Circuit Court of Appeals, No. 20-5193.

Janita Kan and Reuters contributed to this report.

Clipped from: https://www.ntd.com/appeals-court-upholds-trump-rule-requiring-hospitals-to-show-prices-upfront_546698.html