reimbursement

Sutter Health to pay $90M to resolve False Claims allegations

The California-based health system will pay a hefty price to resolve allegations that it knowingly submitted inflated diagnosis codes for certain Medicare Advantage beneficiaries to receive higher payments. Sutter Health does not admit any liability in the matter.

Health insurer Excellus will not fund Alzheimer’s drug Aduhelm

Health insurer Excellus BlueCross BlueShield has said it will not cover treatment with Biogen and Eisai’s new Alzheimer’s disease drug Aduhelm because it has not been shown to be medically effective. The company – said to be the largest health insurer in New York – said in a statement that Aduhelm (aducanumab) remains an investigational …

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Gene therapy specialist bluebird exits “untenable” European market

Europe market has proved so hostile to gene therapies when it comes to pricing and reimbursement for gene therapies that bluebird bio has decided to quit the market altogether, according to Andrew Obenshain, president of its severe genetic diseases unit. On the firm’s second-quarter results call, Obenshain said the biotech will start “an orderly wind-down” …

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Success at a glance: Turning incomplete patient data from COVID-19 testing and vaccinations into valid reimbursable claims

“Experian Health’s speed and ability to speak our business language definitely impressed us,” said ACS president, Tim Anderson. “Some of the claims were valid for only a few more weeks, and we were able to submit them in plenty of time. This is the best, fastest platform we’ve seen to reconcile duplicate and data-deficient records. …

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A roadmap for adopting New Science 

The pandemic’s disruption galvanised the biopharma industry into unprecedented action, demonstrating what’s possible when the global scientific community collaborates in exceptional ways and public-private partnerships drive innovation to address a common need. Can the biopharma industry step up again to shatter industry orthodoxy and create new pathways for innovation, access, and affordability? The adoption of …

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CMS ups Medicare payment for at-home vaccinations to about $75 per dose

CMS is increasing the payment for administering at-home Covid-19 vaccinations from around $40 to $75 per dose. The move comes amid the Biden administration’s push to boost vaccinations nationwide, including among older adults who may not be able to access vaccine sites.

Healthcare bills to pay? Let hi.health pick up the tab

Just over a year ago, hi.health launched an app that takes the legwork out of submitting reimbursement claims to private health insurers. Now, the startup has taken another leap forward, settling users bills immediately.  Fredrik Debong The addition to the hi.health app acts as a digital health expense account, according to the company’s co-founder and …

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32 hospitals in non-Medicaid expansion states sue HHS over payments for low-income patients

The hospitals are pushing HHS to recognize patients eligible for Medicaid under the ACA as “low-income” when calculating Medicare disproportionate share hospital payments in states that did not expand Medicaid. The agency’s refusal to do so resulted in the hospitals receiving lower reimbursements for three years, the lawsuit claims.

Stanford Health Care seeks up to $1.9M from Anthem in new suit

The California-based provider has filed a lawsuit against the payer, claiming Anthem has yet to pay for the care it provided to patients covered by its affiliate. Stanford and Anthem had an implied contract, and if it is not upheld by the court, the provider is seeking $1.9 million in reimbursement.

Navigating the complexities of health coverage and reimbursement beyond the pandemic

Product featured in this article: Coverage Discovery As of the end of March 2021, more than 53 million Americans have been fully vaccinated, allowing for cautious optimism as we prepare for the next phase of the COVID-19 journey. Unfortunately for pharmacists, the vaccination program has compounded many of the challenges of the last 12 months. …

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White paper reveals pathway for digital therapeutics use in Italy

A white paper has outlined a pathway that could allow Italy to realise the potential of digital therapeutics (DTx). The official journal of the Smith Kline Foundation, Tendenze Nuove, has published the paper entitled “Digital Therapeutics, an Opportunity for Italy” earlier this month. The book features insights and recommendations from 40 leading experts in the …

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Assessing the impact of prevalence on pricing of rare disease drugs in Germany

In this first article of a three-part series exploring pricing in Europe, CRA’s Life Sciences Practice team discuss the role that disease rarity plays in reimbursement decisions among payers in Germany. Historically, payers have accepted factors including small target patient populations and high clinical development costs as justifications for the high prices of rare disease …

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2021 market access prospects for Italy

Italy was working up big changes in market access throughout 2020 which will be implemented in 2021. In the latest of a suite of features looking at the biggest markets in Europe, Leela Barham takes stock of what 2021 could bring for market access in Italy. AIFA, the Italian Medicines Agency and the agency tasked …

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The US biosimilar market: Predictions for 2021

It has been five years since the first biosimilar launched in United States market—marking the first steps in expanding access to innovative biologic-based treatments that help patients manage and treat difficult illnesses such as cancer, rheumatoid arthritis, and other life-altering diseases. As we’ve seen over those five years, biosimilars are critical in continuing to provide …

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46 hospitals file suit to reverse HHS bad debt policy

A group of hospitals have sued HHS Secretary Alex Azar, arguing he should reverse a policy that prevents hospitals from getting reimbursed for Medicare-related bad debts pending at outside collection agencies. The policy has raised hospital debt payments by about $1.35 million, the lawsuit claims.

Vertex Pharma’s vision for reimbursement innovation

As regional vice president for Northern Europe & Australia, Simon Lem led the digital launch of Vertex Pharma’s novel cystic fibrosis drug Kaftrio. He tells pharmaphorum about embracing digital change and the need for innovative reimbursement solutions. For Vertex, COVID-19 accelerated a digital transformation much needed for the patients they serve. As the leading developer …

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Covid-19 has presented the possibility of reinventing healthcare delivery and reimbursement must support this

While there are encouraging signs of reimbursement falling in step with the move towards a more value-based healthcare system, what is needed now to further encourage healthcare innovators is to properly rationalize approval processes imposed by the FDA and CMS.

Telehealth Benefits Expansion: Helping Providers Maximize Reimbursement

Patients today expect digital capabilities from their provider and will increasingly choose those who offer digital capabilities. Knowing this, many providers have been working to shift more of the patient journey online, through telehealth and virtual care. Not all care needs to be delivered face to face, and technological advances allow patients to access more …

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