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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28 Jul 2021
Nurses Call on FTC to Investigate Piedmont Healthcare Acquisition
National Nurses United asked the Federal Trade Commission to investigate the Piedmont Healthcare acquisition of 11 hospitals, citing monopoly concerns. Continue Reading
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23 Jul 2021
AMA: Congress Must Reevaluate Medicare Physician Payment System
AMA says Congress seems indifferent to the financial instability of the Medicare physician payment system, which will impose hefty cuts on physician practices in 2022. Continue Reading
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22 Jul 2021
DOJ Recovered $3.1B Following 2020 Healthcare Fraud Investigations
Almost $3.1 billion was returned to the federal government in FY 2020 following healthcare fraud investigations, including $2.1 billion to Medicare Trust Funds. Continue Reading
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21 Jul 2021
Former DaVita CEO Faces Healthcare Labor Market Collusion Charges
A Denver federal grand jury indicted DaVita and its former CEO for allegedly committing labor market collusion and depriving workers of free-market job opportunities. Continue Reading
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20 Jul 2021
Key Quality Payment Program Changes in 2022 PFS Proposed Rule
CMS introduced the first seven MIPS value pathways and other updates to the Quality Payment Program as part of the Medicare Physician Fee Schedule proposed rule. Continue Reading
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19 Jul 2021
CMS Proposes 2022 OPPS Rates, Higher Hospital Price Transparency Penalty
The new OPPS proposed rule would increase penalties for noncompliance with hospital price transparency requirements and increase hospital reimbursement by 2.3% next year. Continue Reading
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19 Jul 2021
6 Groups: Medicare Sequestration Shouldn’t Fund Infrastructure Plan
The AHA and other organizations are urging Congress to reconsider its plans to fund Biden’s infrastructure package at the expense of extending Medicare sequestration. Continue Reading
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13 Jul 2021
CMS Seeks Health Equity, Telehealth in Physician Fee Schedule Rule
The proposed rule for the Medicare Physician Fee Schedule would also implement a $33.58 conversion factor next year, a decrease of over $1 compared to 2021. Continue Reading
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13 Jul 2021
Biden’s EO on US Competition Will Impact Hospital Mergers
An executive order aimed at increasing competition across industries will target healthcare consolidation and, specifically, hospital mergers. Continue Reading
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09 Jul 2021
$21M Settlement Resolves Healthcare Fraud Accusations for OH System
Cleveland Clinic-owned Akron General Health System will pay $21M to settle healthcare fraud allegations involving Medicare claims for illegally referred patients. Continue Reading
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05 Jul 2021
AHA’s Recommendations for Inpatient Medicare Reimbursement in FY22
AHA urges CMS to reassess inpatient Medicare reimbursement for organ acquisition and modify the distribution of residency slots as part of the FY 2022 IPPS proposed rule. Continue Reading
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02 Jul 2021
CMS Proposes New Value-Based Payment for End-Stage Renal Disease
The value-based payment model comes as part of the proposed CY22 End-Stage Renal Disease Prospective Payment System rule, which also updates rates for renal dialysis services. Continue Reading
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02 Jul 2021
Biden Administration Releases Surprise Billing Regulations
The surprise billing regulations are Part I of implementation of the No Surprises Act, a law passed last year that aims to protect patients from unexpected out-of-network bills. Continue Reading
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01 Jul 2021
Hospitals Oppose Using Medicare, Provider Relief Funds on Infrastructure
Major hospital groups are telling lawmakers to find another way to offset spending in a proposed infrastructure package other than Medicare and unspent provider relief funds. Continue Reading
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28 Jun 2021
CMS Proposes $310M Boost, Value-Based Purchasing for Home Health
CMS has released a proposed rule for the Home Health Prospective Payment System in CY22, which aims to expand value-based purchasing and address health equity. Continue Reading
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14 Jun 2021
New Provider Relief Fund Rules Give More Time to Use, Report Money
HHS recently updated Provider Relief Fund reporting requirements, extending the period of availability of funds and reporting periods. Continue Reading
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09 Jun 2021
CMS Increases Medicare Payments for At-Home COVID-19 Vaccinations
CMS will increase Medicare payments by $35 per dose to administer at-home COVID-19 vaccines in an effort to increase the vaccination rate among beneficiaries. Continue Reading
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01 Jun 2021
Biden Requests $133.7B for HHS Budget, Other Health Spending Plans
President Biden has requested a 23% increase for the HHS budget in 2022 as the administration seeks to bolster public health and other top healthcare initiatives. Continue Reading
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25 May 2021
Chiquita Brooks-LaSure Becomes Next CMS Administrator
The Senate confirmed Brooks-LaSure as CMS administrator in a narrow vote earlier today, making her the first Black woman to lead the agency. Continue Reading
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24 May 2021
Court Orders HHS to Recalculate Medicare DGME Payments
The court ruled that HHS unlawfully changed weighting factors assigned to residents and fellows when calculating Medicare Direct Graduate Medical Education Payments. Continue Reading
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20 May 2021
CMS Delays Codifying Definition of “Reasonable and Necessary”
Previously delayed from March 15th to May 15th, the final rule will now be codified on December 15th, giving CMS time to tackle issues raised by stakeholders. Continue Reading
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17 May 2021
Lawmakers Call for Extension of Provider Relief Fund Benefits
With the June 30th deadline to spend unused Provider Relief Funds fast approaching, House Representatives are asking HHS to extend the benefits. Continue Reading
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11 May 2021
HHS Distributes $1B to Rural Health Providers for COVID-19 Relief
Rural health providers, including clinics and hospitals, will use the funds to increase vaccination rates, expand access to testing, and boost vaccine confidence. Continue Reading
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30 Apr 2021
CMS Finalizes Changes to CJR, Joint Replacement Medicare Model
CMS has announced a final rule that changes the Medicare CJR model payment methodology and extends the model for an additional three performance years. Continue Reading
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28 Apr 2021
CMS Proposes $2.5B IPPS Rate Hike, With Eye on Rural, Health Equity
In addition to IPPS rate increases, the rule would also add physician residency slots, incorporate health equity measures to hospital programs, and repeal some price transparency reporting. Continue Reading
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26 Apr 2021
AHA: Federal Budget Should Bolster Healthcare Workforce, Public Health
The group is asking Congress to consider the federal budget’s impact on healthcare, including healthcare workforce and public health during the ongoing pandemic. Continue Reading
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12 Apr 2021
AHA Backs Chiquita Brooks-LaSure as Next CMS Administrator
The hospital industry group praised Brooks-LaSure’s health policy experience, particularly around the Affordable Care Act, ahead of her confirmation hearing. Continue Reading
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09 Apr 2021
CMS Plans 1.3% Medicare Payment Hike for Skilled Nursing Facilities
The agency also proposed several quality measure changes in the latest FY 2022 Skilled Nursing Facility Prospective Payment System proposed rule. Continue Reading
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08 Apr 2021
CMS Proposes Medicare Payment Bump for Rehab, Psychiatric Facilities
Medicare payments are slated to increase 1.8% for inpatient rehabilitation facilities and 2.3% for inpatient psychiatric facilities, according to two proposed rules from CMS. Continue Reading
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30 Mar 2021
Physician Practices Want More from Provider Relief Fund
Lawmakers have been urged to prioritize allocation of Provider Relief Fund money to physician practices after previous distributions went mostly to hospitals. Continue Reading
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18 Mar 2021
Senate Confirms Xavier Becerra as Next HHS Secretary
As HHS Secretary, California AG Xavier Becerra will spearhead the country’s COVID-19 response efforts, including implementation of key provisions in the COVID-19 relief plan. Continue Reading
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15 Mar 2021
New Bill Seeks to Extend Medicare Sequester Moratorium
The bill aims to prevent spending cuts triggered by the American Rescue Plan, including 2%+ cuts to healthcare, by extending the Medicare sequester moratorium. Continue Reading
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11 Mar 2021
Providers Blast Medicare Spending Cuts in COVID Relief Package
The American Rescue Plan triggers automatic cuts as a deficit control measure that will result in $36 billion in Medicare spending cuts in fiscal year 2022. Continue Reading
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08 Feb 2021
Spotlight on the Biden Administration’s Healthcare Team
While many are still awaiting formal appointments, the Biden’s administration healthcare team is taking shape. Continue Reading
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26 Jan 2021
Biden Administration Inherits Slew of Medicare Regulatory Changes
The Trump administration enacted 244 Medicare regulatory changes during the COVID-19 pandemic, leaving Biden with a slew of policies to reconsider or make permanent. Continue Reading
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21 Jan 2021
HHS Pushes Back Deadline for Provider Relief Fund Reporting
As stipulated by the most recent COVID-19 stimulus package, HHS is giving those who received over $10K in payments more time with Provider Relief Fund reporting. Continue Reading
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20 Jan 2021
How Biden’s COVID-19 Relief Plan Could Impact Hospitals
Now that Joe Biden has been inaugurated, the President is looking to act quickly on a $1.9T COVID-19 relief plan that will significantly impact hospitals and other providers. Continue Reading
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19 Jan 2021
HHS Secretary Alex Azar Resigns, Effective Jan. 20
The HHS Secretary’s resignation letter highlighted the department’s COVID-19 response efforts but worried the attacks on the Capitol will tarnish his legacy. Continue Reading
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15 Jan 2021
Seema Verma Resigns as CMS Administrator Ahead of Biden Inauguration
Verma announced via Twitter that she is resigning as CMS Administrator in preparation of administration shake-ups under President Biden. Continue Reading
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15 Jan 2021
CMS Defines “Reasonable and Necessary” Medicare Coverage
A final rule codified how CMS defines “reasonable and necessary” coverage in Medicare, including how it considers private payer coverage. Continue Reading
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13 Jan 2021
Surprise Billing Arbitration Favors Providers, But Rates Are High
Final rate determinations in New Jersey’s out-of-network surprise billing arbitration system are 5.7x higher than the median in-network prices for the same services, a study finds. Continue Reading
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11 Jan 2021
HHS Renews Public Health Emergency, Regulatory Flexibilities
Key regulatory flexibilities impacted by the COVID-19 public health emergency include higher Medicare payments for COVID-19 hospitalizations and telehealth reimbursement. Continue Reading
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05 Jan 2021
Underserved Areas Get Higher CARES Act Provider Relief Payments
CARES Act provider relief payments disproportionately went to medically underserved areas, helping providers in already struggling areas to keep their doors open during the peak of lockdowns. Continue Reading
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04 Jan 2021
HHS Guidance Clarifies Use of Contract Pharmacies in 340B Program
The guidance states that 340B hospitals are entitled to buy covered outpatient drugs at the discounted price, even if they use contract pharmacies. Continue Reading
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30 Dec 2020
AHA: Anti-Kickback Changes Too Narrow to Promote Value-Based Care
Proposed safe harbors under the Anti-Kickback Statute are too focused on risk-based models to truly promote value-based care, AHA argued. Continue Reading
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30 Dec 2020
Appeals Court Throws Out Hospital Price Transparency Challenge
The decision paves the way for new hospital price transparency requirements on Jan. 1 that require the disclosure of payer-specific rates. Continue Reading
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21 Dec 2020
UPDATED: Congress Approves COVID-19 Stimulus, Gives $3B to Provider Relief Fund
Healthcare providers are calling on Congress to remember them during COVID-19 stimulus negotiations to ensure they can continue to provide care during the ongoing pandemic. Continue Reading
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14 Dec 2020
Provider Groups Leery of New Surprise Billing Legislation
Provider groups are concerned about the details of a new surprise billing solution that would hold patients harmless for emergency care and have payers and providers negotiate the rest. Continue Reading
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10 Dec 2020
Bipartisan COVID-19 Relief Bill Would Add to Provider Relief Fund
The Bipartisan Emergency COVID Relief Act of 2020 would add $35B to the Provider Relief Fund and change reporting requirements if approved by policymakers. Continue Reading
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02 Dec 2020
CMS Releases 2021 OPPS Final Rule, Eliminates Inpatient Only List
The 2021 OPPS final rule also maintains payment cuts for hospitals acquiring outpatient drugs under the 340B Drug Pricing Program. Continue Reading
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02 Dec 2020
CMS Finalizes 2021 Physician Fee Schedule, Including E/M Changes
The final rule for the 2021 Medicare Physician Fee Schedule also makes some telehealth expansions from the COVID-19 PHE permanent. Continue Reading
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27 Nov 2020
HHS Clarifies Debated Provider Relief Fund Reporting Requirements
New FAQs on the HHS website address Provider Relief Fund reporting requirements that have led providers to question how they can spend the financial aid. Continue Reading
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24 Nov 2020
HHS Overhauls Key Healthcare Fraud Laws to Advance Value-Based Care
The two final rules will provide new, permanent exceptions in the Stark Law and Anti-Kickback Statute for providers in value-based care arrangements. Continue Reading
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17 Nov 2020
What Healthcare CFOs Can Expect Under a Biden Presidency
While Biden’s legacy under the Obama administration was tied to the Affordable Care Act, so will his presidency. COVID-19, value-based care, and price transparency will also mark the next four years. Continue Reading
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16 Nov 2020
VA Rule Allows Interstate Care Delivery, Promotes Care Access
With the invocation of their Fourth Mission, VA healthcare professionals can practice across state lines to promote access to care during COVID-19. Continue Reading
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04 Nov 2020
CMS Finalizes 1.9% Boost for Medicare Home Health Reimbursement
That is a $390M increase in Medicare home health reimbursement, according to a new final rule that also expands coverage of telecommunications tech and keeps the PDGM’s behavioral adjustment. Continue Reading
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29 Oct 2020
CMS Sets Medicare Reimbursement Rate for COVID-19 Vaccine
An interim final rule sets the Medicare reimbursement rate for administering a single-dose COVID-19 vaccine to about $28, while also ensuring reimbursement for new treatments for the virus. Continue Reading
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28 Oct 2020
CMS Wants to Streamline DMEPOS Reimbursement, Boost Rural Pay
A proposed rule would also expand DMEPOS reimbursement for continuous glucose monitors and external infusion pumps. Continue Reading
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27 Oct 2020
After Pushback, HHS Revises Provider Relief Fund Reporting Rules
The department reversed a controversial Provider Relief Fund reporting rule from September that calculates lost revenues based on net operating income, not projected 2020 budgets. Continue Reading
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27 Oct 2020
Providers Want Congress to Pause Medicare Sequester in 2021, Too
Congress paused the Medicare sequester cuts to provide relief during the COVID-19 public health emergency. Now, leading provider groups are calling for an extension. Continue Reading
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22 Oct 2020
Lawmakers Seek Bipartisan Solution for Physician Fee Schedule Cuts
Rate cuts proposed in the 2021 Medicare Physician Fee Schedule rule would impact some specialties more than others and must be addressed by Congress, a coalition of 229 Representatives stated. Continue Reading
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19 Oct 2020
CMS Reduces Medicare Reimbursement Rate for Some COVID-19 Tests
The base Medicare reimbursement rate for COVID-19 tests using high throughput technology will decrease to $75 next year unless labs can process results in 2 days or less. Continue Reading
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15 Oct 2020
CMS Provides Medicare Reimbursement for More Telehealth During PHE
Medicare reimbursement will be available for 11 more telehealth services for the duration of the COVID-19 PHE, the agency announced. Continue Reading
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12 Oct 2020
CMS Amends Repayment Terms for Accelerated, Advance Payments
Providers now have 1 year from the date CMS issued payments under the Accelerated and Advance Payment Programs before recoupment, among other new repayment terms. Continue Reading
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08 Oct 2020
CMS Releases Guidance on COVID-19 Data Reporting as Medicare CoP
The guidance details COVID-19 data reporting elements and the enforcement process for failing to meet the new Medicare Conditions of Participation. Continue Reading
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05 Oct 2020
HHS Distributes Another $20B in Provider Relief Funds
The latest round of Provider Relief Funds will be available to more behavioral health providers, as well as providers who received funds from earlier rounds. Continue Reading
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01 Oct 2020
Lawmakers Provide Accelerated, Advance Medicare Payment Relief
The latest continuing resolution extends recoupment under the Accelerated and Advance Payment Programs and lowers the interest rate on outstanding balances. Continue Reading
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30 Sep 2020
CMS Streamlines CLIA Certification to Expand COVID-19 Testing
A new “quick-start guide” and online fee payments are streamlining CLIA certification to get labs up and running with COVID-19 testing sooner. Continue Reading
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29 Sep 2020
White House Gives Congress Until Dec. 31 to Ban Surprise Billing
A new executive order directs HHS to take administrative action if Congress fails to pass surprise billing legislation by the end of the year. Continue Reading
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28 Sep 2020
Preparing Providers for Full MACRA Implementation in 2022
ACOs and hospital-based providers will be most impacted by upcoming changes to quality scoring under full MACRA implementation, but with some work, they also have a lot to gain. Continue Reading
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23 Sep 2020
CMS to Expand Prior Authorizations for Certain Ambulance Transports
The Medicare Prior Authorization Model for repetitive, scheduled non-emergent ambulance transport will expand nationwide after saving Medicare $650M over four years in select states. Continue Reading
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23 Sep 2020
HHS Releases Reporting Requirements for COVID-19 Relief Payments
New guidance details reporting requirements for providers who received COVID-19 relief payments of $10K or more from the Provider Relief Fund. Continue Reading
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14 Sep 2020
Hospitals Wage War with Pharma Over 340B Drug Pricing Program Cuts
Thousands of hospitals are urging HHS to stop drug companies from restricting discounts under the 340B drug pricing program; AHA finds 340B hospitals provided $64B in community benefits. Continue Reading
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10 Sep 2020
Preparing for Hospital Price Transparency Rule Compliance
In the latest Healthcare Strategies podcast, a healthcare lawyer explores hospital price transparency rule compliance and different strategies for solving the healthcare cost problem for patients. Continue Reading
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03 Sep 2020
Closer Look at the Inpatient Prospective Payment System Final Rule
CMS recently released the Inpatient Prospective Payment System final rule for the 2021 fiscal year, drawing criticism from industry leaders for some of its new policies. Continue Reading
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02 Sep 2020
CMS Finalizes FY 2021 Inpatient Prospective Payment System Rule
The rule will increase Inpatient Prospective Payment System reimbursement by $3.5B in FY 2021 and advance hospital price transparency efforts. Continue Reading
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26 Aug 2020
CMS Makes COVID-19 Data Reporting a Condition of Participation
In a move hospitals are calling “disturbing,” CMS updated Medicare and Medicaid Conditions of Participation to include COVID-19 data reporting during the PHE. Continue Reading
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19 Aug 2020
CMS Updates Medicare Billing Rules for 20% Add-On COVID-19 Payment
In addition to Medicare billing updates, the federal agency also announced that it will resume routine inspections for all Medicare and Medicaid-certified providers. Continue Reading
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18 Aug 2020
CMS Doles Out $15M in Fines to Nursing Homes During COVID-19
Over 3,400 nursing homes were fined during the pandemic for noncompliance with infection control requirements and failure to report COVID-19 data, CMS reported. Continue Reading
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07 Aug 2020
Inpatient Rehabilitation Facility PPS Rule for FY 2021 Finalized
The final rule from CMS will increase inpatient rehabilitation facility PPS rates by 2.4% starting Oct. 1, 2020, and make permanent some COVID-19 flexibilities. Continue Reading
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05 Aug 2020
CMS to Boost Outpatient Reimbursement, Remove Inpatient Only List
The proposed Outpatient Prospective Payment System rule would increase outpatient reimbursement 2.6% while also continuing controversial 340B drug cuts and eliminating the inpatient only list. Continue Reading
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04 Aug 2020
CMS Proposes to Boost Office Visit Pay, Expand Telehealth Coverage
Among the many changes proposed in the 2021 Physician Fee Schedule rule were telehealth coverage expansions, permanent COVID-19 flexibilities, and higher values for office/outpatient visits. Continue Reading
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03 Aug 2020
CMS Finalizes 2.2% Boost in Skilled Nursing Facility Reimbursement
The agency also finalized 2021 Medicare payment rates for inpatient psychiatric facilities and hospices in addition to the $750M boost in skilled nursing facility reimbursement. Continue Reading
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28 Jul 2020
Lawmakers Propose Changes to MACRA to Boost ACO, APM Participation
The Value in Health Care Act aims to increase APM participation by extending incentives and correcting arbitrary qualification standards under MACRA and the Medicare Shared Savings Program. Continue Reading
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27 Jul 2020
HHS Extends Public Health Emergency, COVID-19 Payment Flexibility
The extension of the public health emergency means providers can leverage key COVID-19 payment and telehealth flexibilities for at least another 90 days. Continue Reading
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27 Jul 2020
HHS Provides More Details on Provider Relief Fund Reporting
A new document provides more information on Provider Relief Fund reporting requirements for healthcare providers who received one or more payments exceeding $10K. Continue Reading
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21 Jul 2020
Hospitals in COVID-19 Hot Spots to Receive $10B in Relief Funds
HHS has started distributing a second round of $10 billion to hospitals with over 161 COVID-19 admissions through June 10, 2020, or one admission per day. Continue Reading
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20 Jul 2020
Appeals Court Rules in Favor of Hospital Site-Neutral Payments
The decision reverses a lower court’s ruling that hospital site-neutral payments for certain outpatient department services overstepped HHS’ statutory authority. Continue Reading
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07 Jul 2020
CMS Proposes Medicare Payment for Use of Home Dialysis Machines
The proposed add-on Medicare payment would help cover the implementation of home dialysis machines at 65% of the MAC-determined per-adjusted per treatment rate for 2 calendar years. Continue Reading
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06 Jul 2020
President Signs Off on Paycheck Protection Program Extension
The Paycheck Protection Program loan application period was extended through Aug. 8, 2020, per a new law signed by President Trump this weekend. Continue Reading
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02 Jul 2020
AHA’s List of COVID-19 Flexibilities That Should Stay and Go
AHA is pushing for telehealth reimbursement and other COVID-19 flexibilities to become a permanent part of the health policy landscape. But other waivers threaten the quality of patient care once the pandemic ends, the group says. Continue Reading
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02 Jul 2020
Hospitals Call for Delay of Price Transparency Rule Due to COVID-19
After hospitals lost a case challenging the price transparency rule, a coalition of industry groups is asking HHS to postpone the rule’s implementation until after the COVID-19 pandemic passes. Continue Reading
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30 Jun 2020
Beyond the Pandemic: Telemedicine Reimbursement and Health Policy
Telemedicine reimbursement and other regulatory flexibilities enabled providers to quickly pivot operations for COVID-19, but temporary policies also poised the health policy landscape for significant change after the pandemic. Continue Reading
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24 Jun 2020
Judge Dismisses Case Against New Hospital Price Transparency Rule
The ruling dealt a blow to hospital groups hoping to prevent HHS from enforcing a hospital price transparency rule that will require the providers to disclose private payers rates in 2021. Continue Reading
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23 Jun 2020
AHA Wants Extension of Emergency Declaration, COVID-19 Flexibilities
HHS should extend the public health emergency declaration beyond July 25, 2020, to continue offering much-needed COVID-19 flexibilities to healthcare providers, the association said. Continue Reading
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18 Jun 2020
OIG Recovered Over $1.5B From Healthcare Fraud Schemes, So Far
Healthcare fraud schemes also resulted in over 900 exclusions from public healthcare programs between the start of the fiscal year on Oct. 1, 2019, through March 31, 2020, OIG reported. Continue Reading
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10 Jun 2020
HHS Releases $15B in Coronavirus Relief to Medicaid Providers
In addition to Medicaid providers, safety-net hospitals will also receive another $10B in coronavirus relief funds, HHS announced. Continue Reading
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09 Jun 2020
New Paycheck Protection Program Rules to Aid Small Providers
New law eases Paycheck Protection Program rules, giving loan borrowers more flexibility to use funds on non-payroll expenses and a longer loan period. Continue Reading
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04 Jun 2020
CMS Extends Next Generation ACO Model, Offers APM Flexibilities
Due to COVID-19, CMS is granting flexibilities to APM participants and altering deadlines for key CMMI programs, including the new Direct Contracting initiative and the Next Generation ACO model. Continue Reading
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03 Jun 2020
Providers Must Act Today to Receive Additional Coronavirus Relief
Providers must submit revenue information to HHS by the end of the day today (June 3) to apply for additional coronavirus relief funds, HHS says. Continue Reading