Chiara Bell

Planning for Medicare - Countdown to 65 Please join Medicare expert and Senior Plan Consultant at Blue Cross Blue Shield of Massachusetts, Susan Flanagan for this lively discussion about Medicare.  Topics Include: •  Medicare and Medicare Parts A and B •  Medicare enrollment timeline •  Medigap plans that supplement Medicare coverage •  Medicare Advantage plans, such as HMOs and PPOs •  Medicare Part D prescription drug plans •  Plans and programs available to early retirees, such as COBRA

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If you click on the link you will see a report called Expense Distribution. I know this report more than you can imagine. It's based on paid claims. It shows that for this plan half the members were essentially self-insured as individuals. If I was the CEO of this company, you can bet I would make sure the rates my employees were paying for their own care were reasonable. If not, I'd be personally liable. #deerhold #ContractRateExplorer #MRFInsights

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Private health plans deny more claims than public plans Commercial health insurance plans deny more claims than public payers, affecting both health care providers and patients. About 21% of people with employer-sponsored insurance reported denied claims, compared with 10% covered by Medicare, according to a 2023 analysis by KFF, and a 2024 survey from Premier found that around 15% of initial claims submitted to private payers, including Medicare Advantage and managed Medicaid plans, are denied, but about 54% of those denials are eventually overturned on appeal. AvMed and UnitedHealthcare have the highest denial rates among major commercial insurers, according to ValuePenguin, and Kaiser Permanente has the lowest. Full Story: TechTarget (1/9) ….another reasonwhy I support Medicare for All - not Medicare Advantage for all which is an insurance wolf in sheep’s clothing.

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Medicare Open Enrollment begins next month (October 15–December 7), so now is the time for #FinancialAdvisors to prepare! #OpenEnrollment is a crucial time for many clients to adjust their coverage, but too often people assume keeping the same coverage year after year (as long as their monthly premium rate doesn’t skyrocket) is a safe strategy. However, as you’ll see in this article for NAPFA - National Association of Personal Financial Advisors Magazine, many factors impact what makes an “optimal” health plan choice. https://lnkd.in/eZf8jPuC

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The April final rule on #supplementalbenefits in #MedicareAdvantage is a big deal requiring immediate action from #healthplans. The Centers for Medicare & Medicaid Services (#CMS) regulations have 3 major components: evidence, eligibility and member awareness. Beginning with the CY2025 bid process, CMS will deny a plan’s bid if it hasn’t demonstrated that its proposed supplemental benefits for the #chronicallyill (#SSBCI) is reasonably expected to improve or maintain the health or overall function of its chronically ill enrollees. CMS is also implementing annual review of SSBCI offerings for compliance. To comply with the final rule, plans must do the following: ▶️ Establish an evidence-based bibliography of clinical literature for each SSBCI offering, showing it can reasonably improve or maintain the health of chronically ill enrollees. All supporting evidence must be published within 10 years of the coverage year. ▶️ Use written, objective criteria to determine an enrollee’s eligibility for SSBCI, ensuring they meet the definition of “chronically ill enrollee” with complex conditions needing intensive care coordination. MAOs must also document when enrollees are deemed ineligible to ensure equitable access to benefits. ▶️ Include an all-channel disclaimer listing the chronic conditions required for eligibility and clarifying that additional criteria may apply. ▶️ Beginning January 1, 2026, MAOs must send mid-year notifications annually each July to each enrollee with unused supplemental benefits. CMS requires the mid-year notice to support #healthequity and inform enrollees about unused supplemental benefits. These new requirements impose huge new operational challenges for plans under tight deadlines. Get cracking now. Full rule: https://lnkd.in/e8GwBmCq

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🛑 "My broker said we can't carve out our #PBM." 🛑 If your broker is telling you this, #selffundedemployer - maybe it's time to find a new broker. Good brokers CAN make this happen. They can help getting a carve out to a transparent PBM. The medical carrier probably will charge (ridiculous) admin fees to integrate with the transparent PBM, but it can be worth the hassle. The rebate fee credits can be tempting to keep your plan fully integrated too. Vertically integrated medical/pharmacy carriers make it very hard to carve out intentionally, because they want all the profit. Just keep in mind, however, lawsuits from breaches of fiduciary duty by plan members can offset those rebate fee credits pretty quickly.... #pharmacy

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Medicare Advantage unrest, Change Healthcare fallout and more big takeaways from insurers’ Q1 https://lnkd.in/eyg48k7e via Healthcare Dive #MedicareAdvantage #ChangeHealthcare #Cybersecurity #CMS #Medicaid

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Healthcare professionals in Florida face a myriad of regulations and requirements set forth by the Agency for Healthcare Administration and other regulatory bodies. The licensing process involves intricate procedures, strict timelines, and adherence to ever-evolving laws. Watch this video to learn how Howell, Buchan & Strong can help you! https://lnkd.in/e2j76-Jq #AHCA #floridahealthcarelaw #FloridaHealthcare #floridaattorney #floridalawyer #HealthcareLicense

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NAIC is pushing #CMS to allow members to leave their #MA plan if their provider terminates their MA plan contract. If this is successful, what would you do? ⏩ Would you rethink Provider contracts, payments, engagement or incentives? ⏩ Would it change your UM/MM, denials or #PriorAuthorization strategy? ⏩ If member retention was suddenly on the line, would you change your approach to provider contracting vis-à-vis #CAHPS and #memberexperience to protect #StarRatings? As more providers leave #MedicareAdvantage and the industry outcry grows, this is a great time for reflection: Could your plan adapt fast enough to not only survive, but thrive, if NAIC is successful? The future of member trust, satisfaction, and retention could depend on it. H/T to Amy Lotven for this great find! #ItTakesAVillage to keep up with all of the moving pieces now that 50% of seniors are in MA!

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The Biden Administration issued their Final Rule on association health plans (AHPs) undoing prior regs that had made it easier for small businesses (and the self-employed) to access lower-cost "large group" insurance coverage. These same large group health plans already cover more Americans than the Medicare program and lower the insurance expenses of big businesses. Paragon Health Institute has a better vision. #insurance #Biden #HR https://lnkd.in/eAh6vtW5

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Great free Seminar on #Medicare updates

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Robert F Kennedy Jr #RFKJr doesn’t have the guts or wherewithal to force the health insurance industry to transparently reveal the magnitude or clinical consequences of insurer prior authorization delays, denials and rationing of physician recommended care. https://lnkd.in/ev6s8Xit

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I don’t even know what to say at this point. “Aledade gospel” A Maryland firm that oversees the nation’s largest independent network of primary care medical practices is facing a whistleblower lawsuit alleging it cheated Medicare out of millions of dollars using billing software “rigged” to make patients appear sicker than they were. The civil suit alleges that Aledade Inc.’s billing apps and other software and guidance provided to doctors improperly boosted revenues by adding overstated medical diagnoses to patients’ electronic medical records. “Aledade did whatever it took to make patients appear sicker than they were,” according to the suit. Aledade was co-founded in 2014 by Farzad Mostashari, a former health information technology chief in the Obama administration, and has welcomed other ex-government health figures into its ranks. In June 2023, President Joe Biden appointed Mandy Cohen, then executive vice president at Aledade, to head the Centers for Disease Control and Prevention in Atlanta. Aledade has grown rapidly behind hundreds of millions of dollars in venture capital financing and was valued at $3.5 billion in 2023. The lawsuit also names as defendants 19 independent physician practices, many in small cities in Delaware, Kansas, Louisiana, North Carolina, Pennsylvania, and West Virginia. According to the suit, the doctors knowingly used Aledade software to trigger illegal billings, a practice known in the medical industry as “upcoding.” None has filed an answer in court. The lawsuit alleges Aledade encouraged doctors to tack on suspect medical diagnoses that paid extra money. Aledade called it finding “the gravy sitting in the [patient’s] chart,” according to the suit. The company “instructed” providers to diagnose diabetes with complications, “even if the patient’s diabetes was under control or the complicating factor no longer existed,” according to the suit. Some medical practices in Delaware, North Carolina, and West Virginia billed the inflated code for more than 90% of their Medicare Advantage patients with diabetes, according to the suit. The lawsuit also alleges that Aledade “rigged” the software to change a diagnosis of overweight to “morbid obesity,” which could pay about $2,500 more per patient. Some providers coded morbid obesity for patients on traditional Medicare at 10 times the national average, according to the suit. “This fraudulent coding guidance was known as ‘Aledade gospel,’” according to the suit, and following it “paid dividends in the form of millions of dollars in increased revenue.” https://lnkd.in/gx4qcqCQ

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New CMS Rules Hope to Curb Consumer Fraud! KFF Health News reports, “Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators.” CMS “credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.” But “now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?” The article says “the clampdown could add complexity to enrollment and slow the process.”

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LESSON TIME!!! What is the Medical Loss Ratio? And how does it impact insurers and how do they work around it! Health insurance companies like our friends at UnitedHealth Group, through ACA) must comply with the Medical Loss Ratio (MLR), a regulation requiring them to pspend a minimum percentage of premium revenue (typically 80-85%) on medical claims and healthcare quality improvement. However, insurers strategically work around this requirement to increase profitability. This has created a perversion of incentives because the only way for the insurance company to increase its profits is to increase its revenue and not cut costs or increase savings… The other alternative is to redirect its revenue to a subsidiary that is not beholden to those rules They can do this in a number of ways. 1. Reclassify administrative expenses as healthcare quality improvements…. Which is surprisingly common. *** it’s why I hate the word quality in the health care space*** 2. Preferentially Drive revenue to subsidiaries like Optum (the pbm and providers) that aren’t beholden to the same regulatory requirements…. That money doesn’t go to provide cost savings to the patient or improving reimbursement to the physician 3. Push cost by increasing deductibles and co-pays and coinsurances to the patient’s Essentially, the MLR has had a paradoxical effect of increasing revenue and subsequently cost… With loopholes that limit patient care Remember these guys aren’t in it for you… They aren’t in it for your patients or theirs They are in it for their shareholders and investors Don’t believe a word of what they say #OrthopedicSurgery #Neurosurgery #SpineSurgery #InterventionalSpine #healthinsurance #medicallossratio #Valuebasedcare

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How American Health Insurers Got So Infuriating https://lnkd.in/eQgfinNr

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There are compensation design best practices, and there are the unique needs of every employed network. HSG Advisors strikes the balance between the two, partnering with health systems to create customized plans that meet financial goals while retaining and rewarding physicians and APPs. https://lnkd.in/g5dVfap5 #healthcareconsulting #compensationplandesign #compensation #physician #healthcareleader #healthsystem