Category: Our Blog
The updated codes were implemented Oct. 1, adding over 50,000 new options.
When you go to the doctor with an illness, Medicare uses a set of codes called the International Classification of Diseases to categorize it, as well as surgeries and other procedures, when the bill is prepared.
The International Classification of Diseases, or ICD, is used by the World Health Organization. As a member of the WHO, the United States uses the ICD. Many industrialized nations have already switched to ICD-10.
This month in the U.S., ICD-10 went into effect with 69,000 codes. It replaced ICD-9, which had 17,000. ICD-9 had been used since 1979. Many argued it was time for an update.
Medical providers have been anticipating the change for months, but the switch to ICD-10 requires nothing from patients.
Seniors should look forward to greater detail in the codes. The new codes contain more detailed entries, and “specify the types, locations and severity of conditions and injuries.” The codes will also grow from 3-5 digits to 7, allowing for greater specificity.
Before, there were no differences in codes to describe which side of the body has a pain, or had a procedure. Now, more than 40% of the new codes contain that distinction. The implementation of ICD-10 could bring slight changes in payments and coverage, so be sure to check with your doctor if you have any questions.
This image shows the differences in categorizing a femur fracture using ICD-9 and ICD-10. From Roadto10.org.
Click here for Medicare’s ICD-10 page.
For a list of FAQ’s on ICD-10, see this helpful list
from Humana’s website.
We want to clarify Guideline 2 written in yesterday’s email newsletter.
You are free to make any decision, we just ask that you are prepared to make it during your scheduled appointment.
Thank you, and we look forward to working with you during the Enrollment Period.
This week, the price of a standard drug used for critical parasitic infections increased from $13.50 to $750 per pill.
The drug, Daraprim, has been a mainstay in treatment for over 60 years. After acquiring the drug in August, the start-up pharmaceutical company called Turing Pharmaceuticals increased the price by 5,000%.
The drug is used to treat toxoplasmosis, a common food-borne disease, that infects those with weakened immune systems. Typically, the drug is taken by babies whose mothers have infections during pregnancy and patients with organ transplants, AIDS, and some types of cancer.
Last month another decades-old drug, Cycloserine, was purchased by Rodelis Therapeutics, who then increased the price from $500 to $10,800 for 30 pills. After the news broke about the Daraprim price hike, Rodelis returned the rights to the drug to the former holder, a non-profit, on Tuesday. Instead of the original $500 for 30 pills, the organization will double the price to $1,050.
This is becoming a more common practice on drugs that are standard in specific, lesser-known illnesses.
“The cases of Daraprim and of the tuberculosis drug, Cycloserine, are examples of a relatively new business strategy – acquiring old, neglected drugs, often for rare diseases, and turning them into costly “specialty” drugs,” the New York Times wrote in an article.
The CEO of Turing Pharmaceuticals is Martin Shkreli, a former hedge fund executive who has been on multiple news channels and vocal on social media since Monday.
He said since he’s shown that companies and their investors can make a profit from rare diseases such as toxoplasmosis, the result will be more education about the illness and better drugs and service for patients.
Many have spoken against him and his company, including the HIV Medicine Association, the Infectious Diseases Society of America, and Democratic Presidential candidates Hillary Clinton and Bernie Sanders.
After the “outrage” at the beginning of the week, Tuesday night Shkreli said he would lower the price, but did not say by how much, or what the new price would be.
This image is from the Kaiser Family Foundation.
In a Kaiser Family Foundation poll, nearly three-fourths of Americans believe we pay more for drugs than people in other countries. In this case, they’re right- the generic version of Daraprim costs about $20 for 100 pills abroad. Drug costs in the United States exceed other countries by far, shown in this chart by the New York Times.
This image is from the New York Times.
Due to the Richmond 2015 UCI Road World Championships and the location of our office, we will be closed Thursday and Friday. We will be back on Monday!
Yogi Berra, the New York Yankees Hall of Famer, died yesterday at 90. Yogi was a great human being, and while he was known for his quotes, he had so many special things about him.
- “When you come to a fork in the road, take it.”
- “Baseball is 90% mental. The other half is physical.”
- “It ain’t over ’till it’s over.”
This photo is from the National Italian American Sports Hall of Fame website.
To read more about price increase of Daraprim, click here.
Visit the Kaiser Family Foundation’s website for more on their survey on prescription drug prices.
Though you may happy with your current plan, you should see what’s on the market.
- “Even if you loved last year’s plan, it’s important for Medicare recipient to shop around from scratch this year.”This is what we always say. It doesn’t hurt to shop around, and you may find an even better plan than your current one.”They really need to do their homework,” says Patricia Barry, author of “Medicare for Dummies” and a features editor at AARP. “If they do, they’re likely to find their best deal, and they’re likely to save a lot of money.”
- “On Medicare.gov, you can enter those drugs (including dosage and quantity) and a tool on the site will rank the plans by which would be cheapest for you, showing how much those drugs would cost on each plan and how much you’ll pay in premiums.”The Medicare Plan Finder on Medicare.gov is the program we use to find the best plans for you. We show you all of the results, and can explain what the differences are: copays, deductibles, prior authorizations, quantity limits, step therapies, etc. We know this program is the best out there.
- “It is complicated,” says Jack Hoadley, a research professor at Georgetown University’s Health Policy Institute. “The differences among plans can be hard to sort out. For those who aren’t Web-savvy, it’s even harder.”The daunting plans, the confusing terms, and the time it takes to make sense of it all can make it seem like it’s not worth it. It is! Plans change every year, and it’s not worth waiting until next year to realize there may be a better plan.
- “I recommend that people have help for doing this,” says Lita Epstein, author of “The Complete Idiot’s Guide to Social Security and Medicare.” “You can go into the drugstores… but obviously they’re going to gear you toward the plans they use.”One of our biggest strengths is that we are not beholden to any companies. We offer all plans to give our clients the greatest amount of choice. We are 100% objective; it truly doesn’t matter to us which plan you choose. We just want to help you find the right one.
Here’s a sample of how clients can save when comparing plans using the Medicare Plan Finder (click to enlarge).
The Annual Enrollment Period is from October 15 – December 7. Contact us today to make sure we have you on our call list to schedule an appointment.
Tom Says:
“This has always been the way to go, and now people are recognizing that. Even if you love your current plan, it will never hurt to see what else is out there.”
To read the article, How to Pick the Right Medicare Part D Plan for You, click here.
Hospice patients in selected facilities will be able to use both palliative care and medical treatments, rather than choosing one or the other, as they currently must.
Beginning in 2016, the program will be conducted over five years in 40 states, including Virginia. Medicare and the federal government hope to find a better way to provide care to those in hospice facilities, and to see if beneficiaries take advantage of having access to both options: hospice care and hospital care.
Currently, many people deny hospice treatment in favor of medical care that treats their illnesses and symptoms.
Hospice care is valued for it’s multifaceted approach to treating the physical, emotional and spiritual needs of the patient and their family. A hospice team typically includes doctors and nurses, grief counselors, social workers and other aides and volunteers that include not only the patient, but the patient’s family, in the process.
The test program relates to a previous announcement by Medicare that they will reimburse doctors for end-of-life care, sometimes referred to as “death panels.” For more information, see our past newsletter on the subject, or visit our Email Archive.
What does Medicare hope to get out of the experiment?
Medicare wants to see if implementing this policy would increase their own costs. Since many beneficiaries already opt for medical care over hospice treatments, and the cost of hospice care is far less than medical care, some speculate that Medicare’s costs won’t go up. If more patients choose hospice care over medical care, then Medicare’s costs could decrease significantly.
Who will the patients be?
Hospice generally serves patients in the last six months of their lives. In addition to those patients, this new program will be open to Medicare beneficiaries with advanced-stage cancer, chronic obstructive pulmonary disease, congestive heart failure or AIDS.
Instead of having to choose between medical treatment and hospice care, Medicare patients in the selected facilities will have access to both. It is a voluntary program.
What else will Medicare be looking at in the study?
In addition to paying attention to their costs with the new policy, Medicare will be evaluating if more patients are using hospice, the quality of care, and the satisfaction of patients and families.
What happens when the program ends after 5 years?
If if the program succeeds in providing patients with more flexibility and lowering Medicare’s costs, Medicaid will likely adopt a similar policy.There are three Virginia hospice facilities included in the program, each with multiple locations.
- Capital Caring, with locations in Aldie, Alexandria, Arlington, Falls Church, Fredericksburg, and the counties of Loudoun/Western Fairfax, and Prince William/Fauquier.
- Mountain Valley Hospice and Palliative Care, which has branches in Hillsville and Stuart.
- Carilion Clinic Hospice, located in Roanoke, Franklin and New River Valley.
The full list of hospices can be found here.
Tom Says:
“I want to hear from you. What do you want to see in our newsletter? Are you interested in any Medicare or senior-related topics you want us to cover? Or, if you like our current newsletters, I want to know that too. Let us know by responding to this email, or emailing me at [email protected].
This fall, Tom is teaching seniors how to use the Medicare Plan Finder.
The Osher Lifelong Learning Institute at the University of Richmond is a program of the School of Professional and Continuing Studies. Classes are offered on topics including literature, travel, culinary arts, history, and health. The University of Richmond is one of 119 Osher Institutes at colleges and universities nationwide.
In 2004, the University of Richmond received an endowment from the Bernard Osher Foundation, which includes lifelong learning for adults as part of its mission.
The website for the Osher Institute says, “There are no entrance requirements, no tests and no grades. In fact, no college background is needed at all. It’s your love of learning that counts.”
Tom’s class is called “Guiding You Through the Medicare Maze”.
It will be held on Tuesday, October 1st from 1:30-3:30 p.m. The cost is $20. The class description reads, “Figuring out Medicare and what’s right for you is no easy task, especially when it comes to medications. Come learn how to naviagte the Part D Plan Finder on medicare.gov and how simple changes can make a big financial difference.”
A membership to Osher is required to attend classes. More information on memberships can be found here.
“We find that our members are eager to learn more about a favorite subject or gather information about something they previously knew nothing about. Many are drawn to our array of history classes, but the offerings are diverse- from a study of the World War II to writing one’s memoirs. Osher members simply love to learn! This is also a very social group of people, and we find that lasting friendships are made and kept among Osher members.”
-Peggy Watson, Director
Osher Lifelong Learning Institute
University of Richmond
[email protected]
Tom Says:
“I have always wanted to do this, and I believe Osher is the perfect vehicle to teach seniors about Medicare. I am excited for the opportunity to give back to the community and to participate in this excellent program. And of course, to guide seniors through the Medicare Maze. I hope to see you there.”
To see the class schedule and brochure from the Osher Institute, click here.
If a patient isn’t admitted, Medicare won’t cover observation care, and won’t cover nursing home care after the patient leaves the hospital. The patient will incur all costs.
What is observation care?
When patients are not sick enough to be admitted to the hospital, but are sick enough to prevent them from going home, they receive observation care.
Under observation care, seniors often don’t know that they haven’t been admitted, because they are receiving care, medicine and treatments. Observation care is considered an outpatient service, though patients stay in the hospital, often overnight, sometimes for days.
What is the new law?
The U.S. Senate passed the NOTICE Act, (officially the Notice of Observation Treatment and Implication for Care Eligibility Act), which requires hospitals nationwide to inform Medicare patients if they are receiving observation care, but have not been admitted. This will allow patients to know up-front that they will have to pay for all of the costs.
President Obama signed the bill last week. The national law will become effective in August 2016.
What about Virginia?
Virginia was the fifth state to pass a version of this law on a state level. During the 2015 General Assembly session, the body passed a law requiring Virginia hospitals to inform patients of their status.
Senator Richard Black (R-Loudoun), the bill’s patron, said to the Richmond Times-Dispatch, “The reason it was brought to my attention was because people are getting some nasty surprises when they discover that they’ve got a bill that’s not covered by insurance, or they think they are moving into a skilled nursing home and they discover that they have not met the requirements for that.”
The law became effective July 1, 2015.
Why is this issue getting so much attention?
Observation care is becoming an increasingly popular option for hospitals. Since 2006, observation care claims have risen 91%. Observation stays of 48 hours or longer are up 450% in the same time period, according to this study.
The reason? Medicare won’t pay for admitted patients that could have been in observation care. So hospitals have begun using observation care more frequently to ensure they are reimbursed.
The companies are suspended from enrolling new customers and marketing to Medicare beneficiaries.
If you have United American or First United American Life, your plan will remain the same, and is not affected by this suspension.
You do not need to change your plan.
United American’s Part D homepage, which says that they are not taking new enrollees. It reads, “Thank you for your interest in our Medicare Prescription Drug Plans. We are not able to take enrollments into our plans at this time.”
United American Insurance Company and First United American Life Insurance Company have the highest rates of complaints in the Medicare Part D program, and had been dealing with those complaints, and other aspects of customer service, inappropriately.
In a letter to the CEO of Torchmark Corporation, which owns United American and First United Life, a Medicare official says the sanctions will start on August 1, 2015. They will continue indefinitely, until the Centers for Medicare & Medicaid Services are convinced that the company’s’ failures have been addressed and corrected, and will be prevented in the future.
Medicare began investigating Torchmark in 2012, when they found multiple violations regarding coverage determinations for Part D, as well as the handling of customers’ appeals and grievances. Torchmark was fined $150,000 in April 2013 for these violations. In a follow-up investigation, Medicare found that Torchmark had not corrected the violations from 2012, and in September 2014, fined them $40,000. Medicare called the problems “widespread and systemic” failures, which had remained uncorrected for over two years.
In the letter, Medicare listed 8 total violations, including:
- Failing to fully address grievances, and failing to resolve grievances within Medicare’s time guidelines, or as cases required.
- Wrongly categorizing coverage determinations as re-determinations, and mislabeling both as grievances or customer services questions.
- Neglecting to forward coverage determinations to the Independent Review Entity in a timely manner.
- Causing improper denials of payment under Part D by neglecting to perform Part B vs. Part D determinations for transplant medications.
- Failing to include specific information about why an enrollee was denied coverage.
- Neglecting to enforce changes recommended by the Independent Review Entity to fix previous violations.
These resulted in unnecessary delays or denials of prescription drugs, financial hardship for customers, lapses in coverage and other consequences, like sending bills to the wrong customers.
Tom says:
Medicare is keeping close tabs on companies that don’t listen to their customers. This is a line you don’t want to cross as a Medicare insurance company. They have sanctioned many companies in the past for this very same issue (see the links below on sanctioned companies). It is good to know that the government has it’s eye on the behavior of Medicare insurance companies.
Read the letter that Medicare sent to Torchmark here.
Medicare has issued sanctions in the past to companies who were negligent. See these links (here, here and here)
for more background information.
If the federal government doesn’t prevent it, the rate increase will take effect in 2016. Find out if you will be affected.
Three groups will likely see higher premiums:
- Those new to Medicare in 2016
- Those whose Part B is not paid through Social Security
- Those with single incomes over $85,000 (or joint incomes over $170,000)
Why might premiums increase?
Medicare’s guidelines require that the prices of Part B premiums cover 25% of Part B expenses. The majority of Medicare beneficiaries pay their Part B premiums through Social Security. There’s a rule that prevents Medicare beneficiaries who pay the lowest amount for Part B from being charged more unless their Social Security is given a Cost of Living Adjustment. This year, a Cost of Living Adjustment is not expected due to low levels of inflation. 70% of Medicare beneficiaries fall into this category, and their premiums can’t be increased. The remaining 30% face a price hike to reach the necessary quota.
What are the chances that the increases won’t occur?
No one can say for sure, but the U.S. Department of Health and Human Services can intervene until this October, when the rates will be finalized. The HHS Secretary has expressed that she would like to prevent an increase of this scope, and could lower the rates if there is enough money in Medicare’s program funds.
Seniors new to Medicare with incomes…
Less than $85,000 ($170,000 if joint)
Could see premiums rise from…
$104.90 to $159.30
Seniors already in Medicare with incomes from…
$85,000 – $107,000 ($170,000 – $214,000 if joint)
$107,000 – $160,000 ($214,000 – $320,000 if joint)
$160,000 – $214,000 ($320,000 – $428,000 if joint)
$214,000 and up ($428,000 and up,
if joint)
Could see premiums rise from…
$146.90 to $233.00
$209.80 to $318.60
$272.20 to $414.20
$335.70 to $507.80
For more information on the potential premium increases, click here.
Starting in 2020, the Medicare Supplement Plan C and Plan F will no longer be available for those NEW to Medicare.
What happened: With broad bipartisan support, Congress passed the Medicare “doc fix” in April. The bill focused on fixing the way Medicare pays physicians, and included big changes to the current Medicare system.
Why: The bill’s primary purpose was to prevent doctors from getting a 21% pay cut, and to overhaul the physician payment formula that Medicare uses. By 2020, Medicare beneficiaries will pay for the Part B deductible on their own.
When: The bill was passed in April. It will go into effect in 2020, but Part B premiums will likely see a small rise next year.
What does it mean: There are three major changes for Medicare beneficiaries:
Those will higher incomes will pay higher premiums. This is expected to affect only 2% of Medicare users– individuals with current incomes of $133,500 or higher, and couples with current incomes of $267,000 or higher.
Everyone will pay higher Part B premiums. The Medicare “doc fix” will increase all program costs. Medicare users’ premiums are required to cover 25% of Part B costs, so Part B premiums have to increase to fill that quota.
Supplemental Medicare Plans will no longer cover Part B deductibles. The C plan and the F plan are the only plans that cover the Part B deductible, so they will no longer be offered in current form to NEW Medicare users.
If you have the C or F plan, you do not need to change your plan just yet. You will not lose your current plan. The C and F plans will not be available to NEW beneficiaries in 2020.