HHS watchdog flags improper payments to hospitals for services provided to hospice patients
Hospitals may face closer scrutiny over a segment of Medicare outpatient billing after the HHS Office of Inspector General (OIG) found improper payments. In a report posted Nov. 18, OIG found that improper payments were prevalent for outpatient services provided to hospice enrollees during a five-year period ending in 2021. Examining a sample size of…
2 drug manufacturers go to court to turn 340B into a rebate program
Two leading drug manufacturers have pressed forward with efforts to reformat the 340B Drug Pricing Program, filing lawsuits against the federal government over the question of whether savings can be offered as cash rebates rather than up-front discounts. Johnson & Johnson took HHS and the Health Resources and Services Administration (HRSA) to federal court in…
An eventful period for healthcare policy looms as Trump and GOP members of Congress prepare to govern
Notes: The opening section of this article was updated Nov. 19 with news about the nomination of Mehmet Oz as administrator of CMS. For information on the healthcare policy agenda for the final two months of the current Congress, see the sidebar at the bottom of this page. The results of the 2024 federal elections…
What the site-of-care shift for joint replacement means for hospitals
Hospital patient volumes mostly have been on an upswing since the worst of the COVID-19 pandemic, but certain trends represent cautionary tales for long-term finances. For example, the latest report (registration required) from Strata Decision Technology shows a year-over-year decline in August of more than 21% for inpatient primary knee replacement procedures. A shift to…
Medicare’s 2025 payment updates: Why hospitals and physicians think the methodologies are flawed
Neither hospitals nor physicians found much reason for encouragement in final 2025 Medicare payment rules released Nov. 1. The rules, which were made available as pre-publication drafts, finalized a 2.9% increase for hospitals under the payment system for Medicare outpatient services and ambulatory surgical centers (ASCs). Meanwhile, physicians were dealt a 2.83% cut that they…
Senate leaders release a blueprint for comprehensive site-neutral payment policies
To the disappointment of hospital groups, two Senate leaders have produced bipartisan policy options for advancing site-neutral payment in Medicare. The framework released Nov. 1 by Sens. Bill Cassidy (R-La.), who is a physician, and Maggie Hassan (D-N.H.) goes further than site-neutral payment plans that were passed by the House as part of broader healthcare…
Navigating regulatory challenges in hospital revenue cycle: the impact on RCM teams and the path forward
The term “regulatory compliance” is often associated with its cost. However, the foundational purpose of regulations is to protect patients and ensure quality care. Most would agree a healthcare system without regulations would be catastrophic. But provider organizations are now burdened with managing compliance under increasingly complex requirements. If they fall short, they can expect…
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…