Latest News and Updates

Providers Required to Bill Medicaid Managed Care Plans in 2017

Starting in January 2017, Ohioans will now be able to access their Medicaid benefits through one of Ohio’s five statewide Managed Care Plans. Once enrolled in a Managed Care Plan, providers will no longer be allowed to bill the state and instead will be required to bill the plan directly. Providers who do not have contracts with the Managed Care Plans may be able to provide services to current patients/clients for a “transition period”.

Beginning January 1, managed care will be mandatory for Medicaid eligible individuals enrolled in the Breast and Cervical Cancer Project (BCCP) program, children in custody (foster care) and adopted children & individuals enrolled in the Bureau of Children with Medical Handicaps (BCMH) program.  Enrollment will be voluntary for individuals enrolled in any of the home and community based waiver programs administered by the Ohio Department of Development Disabilities.

The Ohio Department of Medicaid began sending informational and enrollment notices to members who are not currently enrolled with a Managed Care Plan in August 2016.

For more information about contracting with the Managed Care Plans or how to submit claims, contact the plans’ provider services with questions at the numbers below or by visiting the following link:

http://medicaid.ohio.gov/PROVIDERS/ManagedCare.aspx.

Managed Care Plan Toll Free Provider Services Phone Number Managed Care Plan Website Address
BUCKEYE 1-866-296-8731 www.buckeyehealthplan.com
CARESOURCE 1-800-488-0134 www.caresource.com
MOLINA 1-(855) 322-4079 www.molinahealthcare.com
PARAMOUNT 1-888-891-2564 www.paramounthealthcare.com
UNITEDHEALTHCARE 1-800-600-9007 www.uhccommunityplan.com
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Rachel WinderProviders Required to Bill Medicaid Managed Care Plans in 2017

Rep. Latta Supports the USPSTF Transparency/Accountability Act

  • Thank you Congressman Latta for agreeing to co-sponsor H.R. 1151, the USPSTF Transparency and Accountability Act.
  • USPSTF recommendations were originally created for the purpose of providing supplemental guidance to primary care physicians. Following the passage of the Patient Protection and Affordable Care Act, USPSTF recommendations gained a significantly more prominent role in the determination of Centers for Medicare and Medicaid Services’ coverage decisions and in the establishment of preventive service coverage requirements for private insurers. With such substantive policy issues at stake, the public trust demands that the USPSTF recommendation-development process be entirely transparent and consistent with other federal agencies that create policy and promulgate regulations.
  • Many in the research and medical community believe that the Task Force should embrace the public transparency and accountability protections mandated on traditional government agencies under the Federal Advisory Committee Act (FACA) and the Administrative Procedures Act (APA) and be required to:
    • Be transparent in its methodology
    • Disclose the input it received as part of its public comment periods and explain its analysis of the public comments
    • Provide rationale for accepting or rejecting the input provided by the public
  • There is no better example of the negative consequences of the USPSTF’s current recommendation process and the need for the enactment of H.R. 1151/S. 1151 than the USPSTF’s 2009 and 2016 screening mammography recommendations. These discredited recommendations clearly demonstrate why critical decisions affecting citizens’ access to preventive healthcare services should not be made behind closed doors without the benefit and protection of well-established federal agency transparency requirements.
  • The American College of Radiology is seeking dissolution is seeking a more deliberative, science-driven, transparent and publically accountable process. ACR acknowledges that, procedural issues notwithstanding, at times, USPSTF recommendations appropriately reflect the available evidence and are consistent with the predominant view/assessment of the scientific community. For example, in December 2013, the USPSTF issued a new, higher Grade of “B” to annual LDCT scans for patients who have a long history of heavy smoking and, thus, are at a higher risk of developing lung cancer. This recommendation has resulted in Medicare and private insurance coverage of LDCT exams and will undoubtedly save thousands of lives.
  • ACR urges Congress to enact bipartisan legislation which comprehensively reforms the USPSTF’s membership, research methodology, and public comment process.
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Rachel WinderRep. Latta Supports the USPSTF Transparency/Accountability Act

Cigna First National Insurer to Cover Tomosynthesis as Screening Mammography

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This is great news that we are hopeful turns into a trend among other insurance providers.

In Ohio, the Ohio State Radiological Society (OSRS) is working with the Ohio Department of Insurance and state legislators to bring attention to this issue.

We have taken the position that tomosynthesis should already be covered under the current definition of “screening mammography” in the Ohio Revised Code which is as follows:

“Screening mammography” means a radiologic examination utilized to detect unsuspected breast cancer at an early stage in an asymptomatic woman and includes the x-ray examination of the breast using equipment that is dedicated specifically for mammography, including, but not limited to, the x-ray tube, filter, compression device, screens, film, and cassettes, and that has an average radiation exposure delivery of less than one rad mid-breast. “Screening mammography” includes two views for each breast. The term also includes the professional interpretation of the film. “Screening mammography” does not include diagnostic mammography.

The key words are “including, but not limited to”.

Other insurance providers that are currently covering Tomosynthesis, of which we are aware, include:

  • All Ohio Medicaid/Medicare Providers
  • Aultman Health
  • ProMedica (Paramount Health Plan)
  • Summa Health System (SummaCare)
  • Cigna

Those providers that are denying coverage state the reason is that the technology is “investigational”.

However, the American College of Radiology (ACR) has determined that tomosynthesis is no longer investigational and CMS agrees along with many private insurers across the country.

From Cigna’s Medical Coverage Policy on Screening Mammography:

Digital Breast Tomosynthesis (DBT)

Large prospective and retrospective trials demonstrate the use of screening digital breast tomosynthesis (DBT) (3D mammography) in addition to 2D screening mammography (i.e., 2D) when used for annual screening provides a statistically significant increase in cancer detection rates (including invasive cancers) and a statistically significant decrease in recall rates compared to 2D mammography alone. Although long term studies on survival are lacking, it is reasonable to postulate from large prospective and retrospective trials that the addition of DBT may confer a positive impact on mortality. (emphasis added)

And finally, studies show that adding Tomosynthesis to 2D mammography is actually cost-effective to payers.

HealthImaging (8/23, Pearson) reports, “Adding annual screening tomosynthesis to 2D mammography beginning at age 40 is cost-effective compared with 2D mammography alone,” researchers found. The study, which “incorporated data from a multi-institutional study of more than 450,000 patients, institutional data of 13,000 patients, literature values and Medicare reimbursement rates,” revealed, however, that “net monetary benefits of the extra exam are around three times greater for women in their 40s than for those in their 50s and older.” The findings were published online in the American Journal of Roentgenology.

What are your experiences with Tomosynthesis?  Do you cover the costs?  Do patients have the option to pay out of pocket?  Are insurers paying?  Help us advocate for you by sharing your story.  rwinder@beneschlaw.com; @OhioRadSociety; https://www.facebook.com/OhioRads

 

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Rachel WinderCigna First National Insurer to Cover Tomosynthesis as Screening Mammography

New website

We are excited to launch our new, updated website. Take a look around, and if you have any questions or suggestions, please feel free to contact us. Additional information will eventually be added that we hope you find useful.

 

Social Media

With a renewed focus on social media, we hope to better connect with our members. We encourage you to like us on Facebook and follow us on Twitter.

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Morgan McBeeNew website