Medicare Patient News

Updates on services and programs covered under Medicare to help senior patients achieve optimal health.

Obamacare, Private Medicare Plans Must Keep Updated Doctor Directories In 2016

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Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year. So it’s not always easy to figure out who’s in and who’s out, and many consumers have complained that their health coverage doesn’t amount to much if they can’t find doctors who accept their insurance.

Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year. So it’s not always easy to figure out who’s in and who’s out, and many consumers have complained that their health coverage doesn’t amount to much if they can’t find doctors who accept their insurance.

Article courtesy Susan Jaffe/Kaiser Health News (KHN) is a nonprofit national health policy news service. 

Starting next year, the federal government will require health insurers to give millions of Americans enrolled in Medicare Advantage plans or in policies sold in the federally run health exchange up-to-date details about which doctors are in their plans and taking new patients.

Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year. Networks can also vary among plans offered by the same insurer. So it’s not always easy to figure out who’s in and who’s out, and many consumers have complained that their health coverage doesn’t amount to much if they can’t find doctors who accept their insurance.

Under a rule published last month by the Centers for Medicare & Medicaid Services, Medicare Advantage plans must contact doctors and other providers every three months and update their online directories in “real time.” Online directories for policies sold through healthcare.gov, the health law exchange run by the federal government in 37 states, must be updated monthly, CMS announced in a separate rule.

Inaccuracies in the Medicare Advantage directories may trigger penalties of up to $25,000 a day per beneficiary or bans on new enrollment and marketing. CMS will also use the directories to help determine whether insurers have enough doctors to meet beneficiaries’ needs.

The federal exchange plans could face penalties of up to $100 per day per affected beneficiary for problems in their directories.

“Studies have shown massive error rates in these directories, including states in the federal exchanges,” said Lynn Quincy, associate director for health policy at Consumers Union. “If consumers select a health plan because they believe their hospital or physician is a participating provider and it later turns out that’s an error, right now they rarely have a remedy–they are stuck with that plan for the year.” Read more


Cleveland Hospitals Grapple With Readmission Fines

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By Sarah Jane Tribble, WCPN January 26, 2015 [This story is part of a partnership that includes WCPN/Ideastream, NPR and Kaiser Health News.]

At the Cleveland Clinic’s sprawling main campus, patient Morgan Clay is being discharged.

Clay arrived a couple of weeks ago suffering from complications related to acute heart failure. He’s ready to go home. But before Clay can leave, pharmacist Katie Greenlee stops by the room.

“What questions can I answer for you about the medicines?” Greenlee asks as she presents a folder of information about more than a dozen prescriptions Clay takes.

“I don’t have too many questions,” Clay says. “I’ve been on most of that stuff for a long time.”

Clay is 62 years old and has been on many of the medications since he was in his 20s, when he developed heart problems.

Still, Greenlee wants to make sure Clay understands the importance of taking his pills at the right time and at their full dosage. Not taking medicine correctly is a big reason patients return to the hospital. And research has found that as many as 30 percent of prescriptions are never filled.

Since the Cleveland Clinic began sending pharmacists into cardiovascular patient rooms at discharge, it has drastically reduced its number of readmissions. And that means it has reduced its Medicare fines, mandated by the Affordable Care Act.

But this kind of success in the ACA’s readmissions program, now in its third year, has been hard to achieve for other Cleveland hospitals that serve more poor patients.

This month, the National Quality Forum began a two-year trial period that adjusts Medicare’s metrics to account for poorer patient populations. NQF is a not-for-profit advisory group that works with federal regulators on the penalty metrics. Read more


Medicare Pays Doctors to Coordinate Seniors’ Chronic Care

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Medicare's new fee for care coordination is about $40 a month per qualified patient.

Medicare’s new fee for care coordination is about $40 a month per qualified patient.

BY Lauran Neergaard, Associated Press January 11, 2015 at 3:33 PM EST

WASHINGTON (AP) — Adjusting medications before someone gets sick enough to visit the doctor. Updating outside specialists so one doctor’s prescription doesn’t interfere with another’s.

Starting this month, Medicare will pay primary care doctors a monthly fee to better coordinate care for the most vulnerable seniors — those with multiple chronic illnesses — even if they don’t have a face-to-face exam.

The goal is to help patients stay healthier between doctor visits, and avoid pricey hospitals and nursing homes.

“We all need care coordination. Medicare patients need it more than ever,” said Sean Cavanaugh, deputy administrator at the Centers for Medicare and Medicaid Services.

About two-thirds of Medicare beneficiaries have two or more chronic conditions, such as diabetes, heart disease or kidney disease. Their care is infamously fragmented. They tend to visit numerous doctors for different illnesses. Read more