Medicare Part D Sustainability
Medicare Part D and the Affordable Care Act Medicare Part D first covered Americans in 2005. The Patient Protection and Affordable Care Act (“ACA” or “PPACA”) of 2010 brought noteworthy…
Genetic Test Medicare LCD development Standards
Genetic Test Medicare LCD
Medicare Local Coverage Determinations for Genetic Testing Medicare Technical Assessment for Molecular Assays To determine coverage for genetic test Medicare LCD, the Centers for Medicare and Medicaid (CMS) requires a…
MMSEA PAID ACT and SMART Act
PAID Act Plus SMART Act Requires NGHPs to Report or Pay Penalties The Medicare, Medicaid and SCHIP Extension Act (MMSEA) of 2007 contains mandatory insurer reporting in Section 111 for…
Laboratory CPT Codes
Laboratory CPT Codes Laboratory CPT codes and pathology CPT codes include services primarily reported to evaluate specimens obtained from patients (body fluids, cytological specimens, or tissue specimens obtained by invasive/surgical…
What Does Medicare Cover Under Part B?
1. What Does Medicare Cover under Part B? What does Medicare cover? Medicare is health insurance for: People 65 or older Under 65 with certain disabilities People of any age…
Pandemic Police Powers of a State Should be Least Restrictive
During the pandemic, when an American citizen domiciled in a state is deprived of civil rights by the state, was the deprivation of civil rights done appropriately according to the…
Examples of formulary exclusions (removals) and updates
Formularies and PBMS
What Is a Formulary? In its simplest form, a formulary is a list A drug formulary is a preferred drug list. The list of medications on the formulary changes based…
NSA Provides Guidance to Mitigate VPN Vulnerabilities to Hackers
In October 2020 and April 2021, the U.S. National Security Administration posted advisories regarding known vulnerabilities that Chinese and Russian hackers use to breach U.S. and other networks. Our Observations:…
Esoteric Testing Market Segments
Esoteric Testing Market Segments The esoteric testing market segments can be seen in their simplest form in two areas: chemiluminescence immunoassay enzyme-linked immunosorbent assay radioimmunoassay, mass spectrometry, flow cytometry, real-time…
Requiring Employees to be Tested for Infectious Disease
Employer Required COVID-19 tests for employees, According to the Americans with Disabilities Act, and EEOC Laws According to the U.S. Equal Employment Opportunity Commission: An employer may administer a COVID-19…
Do Risk Corridors Help Health Plan Beneficiaries?
The Supreme Court found that the U.S. Government breached a commitment to Pay $12 Billion to Health Insurers, but are these payments going to help beneficiaries? Introduction The U.S. Supreme…
How do Pharmacy Benefit Managers Determine Pricing?
This is a complex subject—first, some introductory concepts. Then, the details. In healthcare, the intersection of demand, price, quality, and suppliers' sources alone does not determine whether pricing is appropriate.[i]…