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…
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…
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…
FY 2025 IPPS/LTCH PPS Interim Final Rule Summary
HFMA presents a detailed summary of the interim final rule with comment published by CMS in the October 3, 2024, Federal Register revising its previously announced FY 2025 policies and rates for Medicare’s IPPS and LTCH PPS.
HFMA provides a comprehensive, curated list of CMS guidance on the 2-midnight rule/benchmark for use by payers and providers
Health systems nationwide continue to report unjust increases in beneficiary cost-sharing and delays in post-acute care by Medicare Advantage (MA) plans. These delays often result from automatic downgrades that contradict CMS requirements, specifically those relating to the agency’s two-midnight rule/benchmark, which mandates adherence by MA plans to establish agency-directed care standards. Despite the mandate that…
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…
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…