Providers’ winning streak in No Surprises Act QPA litigation ends as appeals court overturns a prior ruling
Healthcare providers incurred a rare defeat in litigation over a key facet of the No Surprises Act, with an appeals court ruling that the original methodology for calculating the qualifying payment amount (QPA) is permissible. The Oct. 30 decision restores language from prior regulations and means insurers can continue to incorporate or exclude certain disputed…
Report suggests the extent to which Medicare Advantage health plans are skirting the two-midnight rule
As hospitals struggle with payer tactics involving denials, a new analysis quantifies the extent to which Medicare Advantage (MA) health plans still avoid paying for inpatient care. The report by Kodiak Solutions examined claims data from more than 1,900 hospitals and found that MA plans categorized hospital visits as outpatient observation stays at a rate…
Providers can expect UnitedHealthcare to undertake closer inspection of coding patterns
Healthcare spending that exceeded expectations is motivating UnitedHealthcare to take a more rigorous look at provider coding practices. For two consecutive quarters, parent company UnitedHealth Group (UHG) has reported that the medical-cost ratio (MCR) of UnitedHealthcare is being impacted by several factors. One is provider coding trends, the company’s leaders said during investor calls. “In…
Finalized appeals processes for Medicare patients will require new hospital protocols in 2025 (updated)
Hospitals should prepare to imminently accommodate new appeals processes and paperwork for some Medicare patients whose status gets changed from inpatient to outpatient observation during a stay. A newly published final rule gives beneficiaries options for appealing such a change. The effective date of the new appeals processes was not announced in the rule, but…
Providers hope to reverse a court’s No Surprises Act ruling that would affect independent dispute resolution
Hospital and physician advocates are urging an appeals court to reverse a district court’s decision that would render No Surprises Act (NSA) arbitration payments unenforceable. In May, two air ambulance companies lost a case in a Northern District of Texas federal court in which they sought payment from Health Care Service Corporation (HCSC) for awards…
Hospital price transparency enforcement should look at pricing data quality, GAO says
In a report on federal oversight of hospital price transparency regulations, the Government Accountability Office (GAO) says CMS should expand its enforcement purview. The report rehashes many of the technical and formatting issues that stakeholders have discussed since the regulations took effect in 2021. But it goes a step further by questioning whether guardrails are…
Despite positive outcomes, coverage of GLP-1 drugs presents complicated questions
The drugs known as GLP-1 receptor agonists bring the potential for improved health to millions but also a bevy of questions and challenges concerning cost and coverage, according to insights in a recent webinar. GLP-1s such as Ozempic and Wegovy initially came to market as a way to control blood sugar for people with type…
Supply chain challenges could mount for hospitals amid extensive hurricane damage to a key facility (updated-9)
Updates Click on the dates to see updates at the bottom of this article page as follows: Nov. 27: An increase in allocations for customers Nov. 12: An update on when allocations will return to 100% Oct. 30: Insights on the changes to saline administration as a result of the hurricane Oct. 25: An update…
New rules have program integrity implications for Medicare, Medicaid stakeholders
CMS in recent days issued a pair of final rules designed to improve aspects of program integrity in Medicare and Medicaid. The Medicare rule was published Sept. 27 and finalized proposals that were published in early July after CMS became aware of significant potential billing fraud involving a specific type of urinary catheter. Premier, Inc.,…
FTC takes legal action against pharmacy benefit managers, citing a distorted drug-pricing structure
A growing dispute between pharmacy benefit managers (PBMs) and government regulators intensified Sept. 20 when the Federal Trade Commission (FTC) filed suit against the three leading PBMs and their affiliated group purchasing organizations (GPOs). The complaint against CVS Caremark, Express Scripts, Inc. (ESI, owned by Cigna) and OptumRx (UnitedHealth Group) seeks to address a system…