LAByrinth

Update on Peer Review

Proposed new centralization updates to their peer review process for “grants, cooperative agreements, and research and development contracts within the agency’s Center for Scientific Review (CSR)” have been made by the National Institutes of Health (NIH).

The centralization effort will apply to the first stage of the review process. NIH’s CSR ensures independent, expert reviews without inappropriate influence. CSR manages the peer review process for over 78% of NIH grants.

Click here for details from the NIH.

Laboratory Fraud of the Month

The MA Attorney General announced indictments against several MassHealth providers for urine tests and at-home services that weren’t provided, and/or were medical unnecessary, or/or weren’t properly authorized.

The entities involved (which includes two laboratories) and their owners, were allegedly involved in close to $8 million in fraudulent MassHealth claims to Medicare.

The allegations include how one of the players is a physician who authorized home health care services and laboratory tests even though that physician hadn’t seen those patients or provided any care to them, and that many of the patients involved were hospitalized or deceased during the time the supposed services were provided.

Click here for details from the MA Attorney General’s office.

Copays Only/No Deductibles? Yes.

United Healthcare (UHC) has a group plan called Surest. Perhaps unsurprisingly, it happens to be UHC’s best-selling plan. Surest features copays only with no deductibles, no coinsurance, and no cost shifting.

Health Care Service Corporation (HCSC) has its own version of this with their “Simplified Health Care Coverage Option.” If you’re not familiar with HCSC, under its auspices are Blue Cross Blue Shield of IL, MT,

NM, OK, and TX. Apparently, the “no deductibles/copays only” concept is catching on.

What do these insurance plans potentially mean for clinical laboratories and anatomic pathology groups? No doubt there’d be reduced patient A/R since responsibility balances for deductibles wouldn’t exist under those plans.

Click here for details from the HCSC press release

(Regardless of your patients’ insurance coverage, ADSRCM empowers you to capture responsibility balances to the best extent possible with access to our patient responsibility estimator, with out-of-network alerts, with an automated prior authorizations option, with our team performing eligibility verifications up to four times prior to tests, and with a balance due reminder texting option.)