Healthcare payment policy and regulation
Payment policy and regulation encompasses the various rules, guidelines and laws governing healthcare's financial aspects, including Medicare and Medicaid reimbursement rates, medical billing, and claims administration. Payment policy and regulation also plays a critical role in shaping the healthcare landscape, affecting service accessibility and affordability.
Top Stories
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04 Nov 2024
CMS highlights maternal care in CY 2025 OPPS, ASC final rule
The CMS CY 2025 OPPS, ASC final rule aims to reduce maternal mortality, remove barriers to care for formerly incarcerated individuals and enhance health equity. Continue Reading
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04 Nov 2024
CMS finalizes CY 2025 Medicare physician fee schedule rule
CMS issued the CY 2025 Medicare physician fee schedule final rule, which included updates to payment policies and average payment rate reductions. Continue Reading
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25 Oct 2024
Has hospital price transparency affected healthcare costs?
Data indicates that hospital price transparency laws have caused healthcare costs to level off. Continue Reading
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17 Oct 2024
Medicare drug price negotiations impact non-chain pharmacies
Although Medicare drug price negotiations intend to expand medication access, independent pharmacies are facing challenges associated with reimbursement and PBM strategies. Continue Reading
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02 Oct 2024
Hospital consolidation shrinks metro inpatient care market
Just one or two health systems controlled the entire inpatient hospital care market in nearly half of metropolitan areas in 2022, highlighting hospital consolidation trends. Continue Reading
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30 Sep 2024
Inflation Reduction Act cuts costs of 54 prescription drugs
Medicare Part B enrollees will see lower prescription drug costs due to a rebate program under the Inflation Reduction Act. Continue Reading
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18 Sep 2024
Do hospital mergers and acquisitions drive physician burnout?
Half of physicians said hospital mergers and acquisitions affect their job satisfaction, contributing to medicine's physician burnout woes. Continue Reading
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04 Sep 2024
Private equity hospice ownership data scant despite PE moves
Hospice ownership data is hard to come by, limiting efforts to understand the impacts of private equity activity. Continue Reading
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22 Aug 2024
Judge blocks FTC noncompete ban
A Texas judge blocked the FTC noncompete ban just weeks before it was set to take effect, sparking mixed reactions from the healthcare community. Continue Reading
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15 Aug 2024
White House settles Medicare drug price negotiations
The Medicare drug price negotiations are slated to save the federal program around $6 billion across 10 selected medications. Continue Reading
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05 Aug 2024
Hospitals get $2.9B increase in Medicare inpatient pay
HHS finalized a rule that will increase Medicare inpatient payments by 2.9% in FY 2025, among other new payment policies. Continue Reading
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11 Jul 2024
CY 2025 Physician Fee Schedule rule seeks a 2.8% payment cut
CMS proposed the CY 2025 Medicare Physician Fee Schedule rule to update payment policies and expand access to behavioral health and value-based care. Continue Reading
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10 Jul 2024
CMS proposes CY 2025 OPPS, ASC payment system rule
The CY 2025 OPPS and ASC payment system rule looks to grow Medicare payments to facilities, health equity and access to behavioral health. Continue Reading
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08 Jul 2024
CMS proposes CY 2025 ESRD Prospective Payment System rule
The CY 2025 ESRD Prospective Payment System rule would increase Medicare payments to facilities by 2.2%, among other policies. Continue Reading
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11 Jun 2024
AHA has “strong concerns” about IPPS payment updates
The leading hospital association said proposed payment updates to the Inpatient Prospective Payment System are inadequate considering financial challenges. Continue Reading
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22 May 2024
Cleveland Clinic settles False Claims Act allegations for $7M
The Cleveland Clinic Foundation paid over $7M to resolve False Claims Act allegations around federal grant applications. Continue Reading
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21 May 2024
Providers seek $758M for children’s hospitals GME program
Over two dozen trade groups seek more funding for the Children’s Hospitals Graduate Medical Education program to bolster the pediatric physician workforce. Continue Reading
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14 May 2024
Breaking down the FTC noncompete ban, its impact on healthcare
The FTC recently prohibited noncompetes, a popular clause used in healthcare employment agreements, but legal challenges and clarifications are on the horizon. Continue Reading
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13 May 2024
DoJ forms task force on competition, monopolies in healthcare
The Task Force on Health Care Monopolies and Collusion will guide the Justice Department’s enforcement strategy and policy approach in healthcare. Continue Reading
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07 May 2024
Medicare funds slated to run out by 2036 without changes
Medicare received a few more years before it runs out of money, but the outlook is still grim without changes to rapid spending growth, the trustees report. Continue Reading
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23 Apr 2024
CMS sets minimum staffing standards for nursing homes
A new rule from CMS establishes at a national level a minimum total of 3.48 hours of nursing care per day, among other staffing standards. Continue Reading
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23 Apr 2024
Portal allows public reporting of anti-competitive behaviors
The federal government has opened an online portal for public reporting of anti-competitive behaviors in healthcare in an effort to fairer markets. Continue Reading
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22 Apr 2024
HHS finalizes 340B Administrative Dispute Resolution process
A new rule from HHS finalizes an Administrative Dispute Resolution process, which allows covered entities to address disputes with drug companies. Continue Reading
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01 Apr 2024
CMS proposes FY 2025 Medicare payment rates for hospice, IPFs
Medicare payment rates would increase by 2.6% for hospices and IPFs, respectively, in FY 2025 as CMS calculates the impact of several policy changes. Continue Reading
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27 Mar 2024
2024 MIPS Changes and Their Impact on Emergency Medicine
CMS continues to shift the MIPS reporting process with a new model specifically designed to align with physician specialties, like emergency medicine. Continue Reading
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22 Jan 2024
New Reality of Medicare Physician Payments, Future with MIPS
Medicare physician payments have always been a source of debate, leading to several changes in its payment model as it continues its shift to value-based care. Continue Reading
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19 Jan 2024
Provider Groups Say Final Rule Will Relieve Prior Authorization Burdens
Provider groups, including the American Medical Association and the Medical Group Management Association, said the final rule will help streamline prior authorization processes. Continue Reading
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19 Dec 2023
Feds Finalizes $115 Participation, Other Fees for IDR Process
The new fees come after a court ruling vacated previous guidance used to set the administrative payment amount for the federal IDR process. Continue Reading
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05 Dec 2023
Hospitals Concerned About Medicaid State-Directed Payment Changes
Several hospital associations urge CMS not to finalize proposed restrictions on provider-based Medicaid funding for state-directed payments. Continue Reading
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15 Nov 2023
Regulatory Burdens in Healthcare Take Away from Patient Care
Practice leaders overwhelmingly agree reducing prior auths and other regulatory burdens would allow resource reallocation, MGMA says. Continue Reading
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03 Nov 2023
CMS Will Issue OPPS Providers Lump-Sum Payments to Remedy 340B Losses
CMS also finalized a 3.8 percent increase in OPPS payment rates and adjusted price transparency policies. Continue Reading
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03 Nov 2023
CMS Finalizes 1.25% Cut To Medicare Physician Fee Schedule
CMS finalized a conversion factor of $32.74 for the CY 2024 Medicare Physician, representing a 3.4% cut versus CY 2023. Continue Reading
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02 Nov 2023
CMS Finalizes a $140M Increase to Medicare Home Health Payment Rates
The rule finalized a Medicare payment rate boost for home health agencies and changes to the Home Health Quality Reporting Program. Continue Reading
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01 Nov 2023
CMS Boosts End-Stage Renal Disease Medicare Rates by 2.1%
Facilities under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) will also see higher Medicare rates for new drugs, according to a final rule. Continue Reading
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25 Aug 2023
AHA Calls for Easier On-Ramp for Bundled Payments, Episode-Based Payments
The organization said CMS should offer resources and a better “on-ramp” for those transitioning to bundled payments and taking on more risk. Continue Reading
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01 Aug 2023
Inpatient Providers Will Receive 3.1% Reimbursement Increase in FY24
The payment update in the IPPS final rule translates to a $2.2 billion increase for inpatient providers in 2024. Continue Reading
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01 Aug 2023
CMS Increases 2024 Skilled Nursing Facility Payments by 4%
The final rule also included changes to the Skilled Nursing Facility Quality Reporting Program and Value-Based Purchasing Program. Continue Reading
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28 Jul 2023
CMS Boosts FY24 Payment Rates for Inpatient Psychiatric and Rehab Facilities
Payments rates will increase by 2.3 percent for inpatient psychiatric facilities and 4.0 percent for inpatient rehabilitation facilities. Continue Reading
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17 Jul 2023
MIPS Value Pathways: Pros and Cons for Emergency Medicine Physicians
MIPS Value Pathways provide emergency medicine physicians with a new MIPS reporting option, but the alternative may not be for everyone. Continue Reading
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14 Jul 2023
CMS Proposes Payment Cuts in CY24 Medicare Physician Fee Schedule
In addition to payment cuts, the agency proposed changes to the Quality Payment Program and the Medicare Shared Savings Program. Continue Reading
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14 Jul 2023
OPPS Rule to Update Outpatient Payments, Hospital Price Transparency
CMS proposes in the OPPS rule to boost outpatient payments by 2.8% next year and increase hospital price transparency compliance. Continue Reading
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10 Jul 2023
CMS to Resolve 340B Payment Mix-Up With $9B Lump-Sum Fix
The payments will go to approximately 1,600 hospitals impacted by a 340B payment cut shot down by the Supreme Court last year. Continue Reading
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05 Jul 2023
CMS Proposes $375M Cut to Medicare Home Health Payments
Medicare home health payments are slated to decrease by 2.2% next year as CMS enacts a statutory cut and continues PDGM implementation. Continue Reading
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27 Jun 2023
CMS Proposes 1.6% Payment Increase for ESRD Facilities
The federal agency also proposes in a new rule to adjust Medicare payments to ESRD facilities for certain new renal dialysis drugs and biological products. Continue Reading
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20 Jun 2023
Lawmakers Seeking Stakeholder Input to Improve 340B Drug Pricing Program
The request for feedback follows reports of ambiguity and concerns about program integrity in the 340B Drug Pricing Program. Continue Reading
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05 Jun 2023
CMS Withdraws COVID-19 Vaccine Mandate for Healthcare Workers
The final rule from CMS comes after the White House said in May the federal government would wind down certain COVID-19 vaccine requirements. Continue Reading
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25 May 2023
Eye Specialists Pay $17M to Resolve False Claims Act Violations
SouthEast Eye Specialists allegedly induced optometrists to initiate patient referrals to its practice, which were reimbursed by Medicare and TennCare, violating the False Claims Act. Continue Reading
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02 May 2023
HHS to Start Unwinding COVID-19 Vaccine Requirement
HHS is starting the process of ending the COVID-19 vaccine requirement for CMS-certified healthcare facilities as the Biden Administration ends some broader vaccine mandates. Continue Reading
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27 Apr 2023
CMS Cracks Down on Hospital Price Transparency Compliance
CMS has updated enforcement procedures for hospital price transparency compliance, including earlier and automatic financial penalties. Continue Reading
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21 Apr 2023
HHS Sheds Light on Hospice, Home Health Ownership Data
The federal department has released ownership data for all Medicare-certified hospice and home health agencies to increase healthcare transparency. Continue Reading
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18 Apr 2023
House Oversight Panel Investigates COVID-19 Relief Allocation
House Committee on Oversight and Accountability leaders say HHS funneled billions of COVID-19 relief funds to “highly profitable hospitals” while rural hospitals battled bankruptcy. Continue Reading
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11 Apr 2023
CMS Releases FY24 IPPS Proposed Rule, Seeks to Boost Rates by 2.8%
The proposed rule for the FY24 Inpatient Prospective Payment System (IPPS) would also add quality measures and recognize homelessness as an indicator of resource utilization. Continue Reading
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06 Apr 2023
Lawmakers Want to Tie Physician Payment Updates to Inflation
The bill introduced by a coalition of doctors in Congress aims to address the physician shortage for Medicare beneficiaries because of physician payment uncertainty. Continue Reading
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05 Apr 2023
CMS Proposes a 3.7% Boost in Skilled Nursing Facility Payments
The $1.2 billion proposed payment increase for skilled nursing facilities reflects a $2 billion boost from the market basket update and a $745 million reduction for PDPM parity adjustment. Continue Reading
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04 Apr 2023
Proposed Rule to Boost Medicare Inpatient Rehab Payments by 3%
The proposed rule would grow payments to inpatient rehabilitation facilities (IRFs) by $335M in FY 2024 and relax billing limitations on new IRF units. Continue Reading
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03 Apr 2023
AHA, AHIP Urge Supreme Court to Uphold False Claims Act Ruling
The organizations disagreed with the federal government’s view that entities are responsible for understanding complex regulations in order to avoid liability under the False Claims Act. Continue Reading
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03 Apr 2023
CMS Proposes 2.8% Medicare Hospice Payment Bump
CMS has released a proposed rule updating hospice payments for the 2024 fiscal year and requesting stakeholder feedback on transparency and health equity at hospice agencies. Continue Reading
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03 Apr 2023
The Battle For Fair Reimbursement Under The No Surprises Act
Implementation of the No Surprises Act, including the independent dispute resolution process, could lower reimbursement for physicians, especially in emergency medicine. Continue Reading
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21 Mar 2023
CMS Resumes IDR Payment Determinations Under No Surprises Act
Certified IDR entities can resume payment determinations for disputes after Oct. 25, 2022, after CMS paused the No Surprises Act process following a court's ruling. Continue Reading
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09 Mar 2023
AMGA Opposes Proposed Medicare Advantage Coding Changes
Proposed coding changes, including the removal of more than 2,000 codes from the HCC model, would negatively impact providers in value-based arrangements and hinder care access for patients with chronic conditions, AMGA said. Continue Reading
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24 Feb 2023
CMS Proposes to Implement Changes to Medicaid DSH Calculations
The proposed rule would implement changes to Medicaid’s hospital-specific Disproportionate Share Hospital (DSH) cap calculations from the Consolidated Appropriations Act of 2021. Continue Reading
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14 Feb 2023
AMA Urges CMS to Finalize Medicare Advantage Prior Authorization Reforms
AMA asked CMS to finalize several prior authorization reforms, including the requirement that plans only use prior authorization to confirm diagnoses and ensure the medical necessity of services. Continue Reading
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10 Jan 2023
CMS Awards 200 Residency Slots to Bolster Healthcare Workforce
The 200 Medicare-funded residency slots are part of a larger plan to add 1,000 new physician places to qualifying hospitals over five years to boost the healthcare workforce and health equity. Continue Reading
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21 Dec 2022
HHS Releases Ownership Data on All Medicare-Certified Hospitals
Releasing ownership data on Medicare-certified hospitals will boost healthcare transparency and promote competition, HHS says. Continue Reading
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21 Dec 2022
How the 2023 Physician Fee Schedule Impacts Emergency Medicine Groups
The 2023 Physician Fee Schedule contains Medicare reimbursement cuts, coding policy updates, and MIPS changes that will impact emergency medicine groups next year. Continue Reading
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20 Dec 2022
Congress to Halve Medicare Payment Cuts Via Year-End Spending Package
Physicians are facing a 4.5% reduction in Medicare payments next year, but Congress’ year-end spending package would reduce that to 2%. Continue Reading
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15 Dec 2022
National Healthcare Spending Grows 2.7% as COVID-19 Relief Runs Dry
National healthcare spending grew at a slower rate compared to 2020, but still reached a total of $4.3 trillion last year. Continue Reading
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12 Dec 2022
Providers Leaving No Stone Unturned to Stop Medicare Payment Cuts
Healthcare industry groups are banding together to urge Congress to prevent 4.5% in Medicare payment cuts from happening on Jan. 1st. Continue Reading
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06 Dec 2022
HHS Gives Providers More Time for Good Faith Estimate Compliance
Enforcement discretion for certain parts of good faith estimate (GFE) compliance has been extended due to a lack of technical infrastructure. Continue Reading
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05 Dec 2022
Unpacking the No Surprises Act, Its Impact on Emergency Medicine
The No Surprises Act protects consumers from surprise medical bills, but the law and related regulations have put emergency medicine in a pinch as more providers face lower OON payments and IDR delays. Continue Reading
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30 Nov 2022
HHS Proposes Changes to 340B Administrative Dispute Resolution
The proposed revisions would make the 340B Administrative Dispute Resolution process more accessible, align the approach with statutory provisions, and introduce a reconsideration process for dissatisfied parties. Continue Reading
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29 Nov 2022
House Committee Requests Changes to Final Surprise Billing Rule
The final surprise billing rule still pushes independent dispute resolution entities to consider the qualifying payment amount over other factors, the House Committee on Ways and Means said. Continue Reading
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29 Nov 2022
NY Gov. Signs Legislation Prohibiting Property Liens Over Medical Debt
The legislation furthers Governor Hochul’s goal to protect New Yorkers from abusive financial practices and address medical debt among consumers. Continue Reading
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21 Nov 2022
HRSA Opens Portal for Late Provider Relief Fund Reporting
The Provider Relief Fund portal will be open from November 14 to December 2, 2022, for providers to report how they used payments received between January 1 and June 30, 2021. Continue Reading
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02 Nov 2022
CMS Settles on Physician Fee Schedule Conversion Factor Cut of $1.55
The agency released the CY23 Physician Fee Schedule final rule, which will also expand access to behavioral health and other "whole-person" services. Continue Reading
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02 Nov 2022
OPPS, ASC Final Rule Boosts Medicare Reimbursement by 3.8%
In addition to higher Medicare reimbursement, the OPPS and ASC final rule includes policies to improve health equity in rural and underserved communities. Continue Reading
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01 Nov 2022
CMS Finalizes Medicare Reimbursement Increase for ESRD Facilities
The Medicare reimbursement update will boost payment to end-stage renal disease facilities by $7.9 billion in 2023. Continue Reading
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01 Nov 2022
Home Health Agencies Get $125M Payment Boost from Medicare
The CY23 Home Health Prospective Payment System Rate Update final rule also updates the Patient-Driven Groupings Model and quality reporting programs for home health agencies. Continue Reading
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25 Oct 2022
FAH Urges Congress to Pass Legislation to Limit Medicare Payment Cuts
Waiving the PAYGO sequester requirements and updating the 2023 Medicare Physician Fee Schedule would help limit Medicare payment cuts to hospitals, FAH wrote. Continue Reading
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25 Oct 2022
Some State Surprise Billing Resolution Processes Favor Providers
Most states use the federal independent dispute resolution system to resolve surprise bills, but some state systems are working better for providers, a new report shows. Continue Reading
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24 Oct 2022
CMS Increases Oversight Policies for Low-Performing Nursing Homes
Low-performing nursing homes in the Special Focus Facility program will now have to demonstrate systemic quality improvements before exiting the program. Continue Reading
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06 Oct 2022
CMS Seeks Input on National Directory of Healthcare Providers
In a request for information, CMS said a national directory of healthcare providers and services would help patients navigate the healthcare system and facilitate care coordination. Continue Reading
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05 Oct 2022
SCOTUS Won’t Hear Healthcare Vaccine Mandate Case Again
Missouri’s healthcare vaccine mandate challenge is not on the Supreme Court’s docket following its January decision to uphold the mandate while the lower courts heard the case. Continue Reading
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27 Sep 2022
TX Doctors Sue Feds Over Surprise Billing IDR Process, Again
The Texas Medical Association is suing the feds again despite changes to the implementation of the surprise billing law’s independent dispute resolution process following a successful 2021 lawsuit. Continue Reading
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21 Sep 2022
Observation Care CPT Updates to Impact Emergency Physician Reimbursement
New 2023 CPT guidelines for patients in observation status classify this care as an inpatient service and add new requirements for emergency physician reimbursement. Continue Reading
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20 Sep 2022
HHS Requests Stakeholder Feedback on Good Faith Estimate Requirements
The request for information seeks feedback on transferring data from providers to health plans, policy considerations, and the economic impacts of implementing good faith estimate requirements. Continue Reading
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19 Sep 2022
AHA Responds to Medicare Outpatient Payment Updates for CY 2023
The proposed outpatient payment updates for 2023, including the 2.7 percent reimbursement increase, do not reflect the inflationary environment in which hospitals are operating, AHA said. Continue Reading
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08 Sep 2022
Healthcare Orgs Request Medicare Shared Savings Program Updates in PFS
AMA and NAACOS have urged CMS to expand advanced shared savings payments to more ACOs to increase participation in the Medicare Shared Savings Program. Continue Reading
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26 Aug 2022
CMS Delays Radiation Oncology Model With No New Start Date
CMS says it will propose a new start date for the controversial Radiation Oncology Model via future rulemaking. Continue Reading
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25 Aug 2022
CA Healthcare Organizations Settle False Claims Act Violations
The False Claims Act settlements alleged that the healthcare organizations knowingly submitted improper Medicaid claims for services provided to California’s Medicaid expansion population. Continue Reading
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24 Aug 2022
AHA Voices Concerns About Home Health Medicare Reimbursement Update
AHA said that the 2.7 percent Medicare reimbursement update for home health agencies does not accurately reflect the financial challenges that home health agencies have faced during the pandemic. Continue Reading
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23 Aug 2022
CMS Releases Guidance on Independent Dispute Resolution Process
The guidance details how parties can initiate the independent dispute resolution process online and includes common mistakes parties should avoid during the process. Continue Reading
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22 Aug 2022
Biden Administration Releases Final Surprise Billing Rules
The final surprise billing rules downgrade the weight the QPA has on out-of-network payment determinations and establishes documentation requirements for downcoding situations. Continue Reading
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18 Aug 2022
CMS Suspends Certificates of Medical Necessity, DME Forms for 2023
According to stakeholder feedback, submitting Certificates of Medical Necessity and Durable Medical Equipment Information Forms was challenging and burdensome for small and rural providers. Continue Reading
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16 Aug 2022
Will Medicare Physician Fee Schedule Changes Drive Value-Based Care?
ACO support included in the CY 2023 Medicare PFS proposed rule will boost value-based care participation only for provider groups who were already considering the shift, according to healthcare attorneys. Continue Reading
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15 Aug 2022
Federal Judge Rejects Surgeon’s Challenge of No Surprises Act
US District Court Judge Ann Donnelly denied surgeon Daniel Haller’s motion for an injunction of the No Surprises Act, which has banned surprising billing since January. Continue Reading
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10 Aug 2022
HHS Allocates $60M to Address Rural Healthcare Workforce
The investment includes $46 million in American Rescue plan funding to strengthen the rural healthcare workforce through job development, training, and placement. Continue Reading
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08 Aug 2022
CMS Nixes MIPS Facility-Based Scoring for 2022 Performance Year
MIPS facility-based scoring will not be available after the FY 2023 IPPS final rule suppressed several measures in the Hospital VBP Program. Continue Reading
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04 Aug 2022
MGMA Requests Longer Notice Before Surprise Billing Enforcement
The quick turnaround time between final rule publications on surprise billing requirements and enforcement dates has created significant administrative burden for healthcare practices, MGMA said. Continue Reading
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02 Aug 2022
CMS Releases FY23 IPPS Rule, Boosts Hospital Reimbursement by 4.3%
The FY 2023 Inpatient Prospective Payment System (IPPS) rule adds $2.6B to hospital reimbursement and advances health equity. Continue Reading
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01 Aug 2022
CMS Final Rule Boosts Medicare Payments for Skilled Nursing Facilities
The FY 2023 SNF PPS final rule nixed the proposed decrease in Medicare payments for skilled nursing facilities and established a $904 million reimbursement increase. Continue Reading
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01 Aug 2022
FAH Asks HHS, CMS to Extend COVID-19 PHE, Regulatory Waivers
The regulatory waivers and flexibilities tied to the COVID-19 public health emergency declaration help hospitals continue to provide patient care during the pandemic, FAH wrote. Continue Reading