Understanding the signals amid the noise: What’s really happening with Medicare Advantage?
In healthcare circles, the buzz continues: Providers are exiting Medicare Advantage (MA) arrangements in large numbers. An HFMA survey found that 19% of provider organizations stopped accepting one or more MA plans in 2023 with almost 60% of respondents either planning or considering a pause on one or more MA plans in the next 24…
CY 2025 End-Stage Renal Disease PPS Final Rule Summary
HFMA presents a detailed summary of the final rule updating the end-stage renal disease prospective payment system for CY 2025.
2 proposed rules seek to stem insurers’ use of prior authorization, medical management
In its waning days, the Biden administration hopes to lay additional groundwork for curbing health plan policies regarding prior authorization in Medicare Advantage (MA), along with group health plan tactics that may interfere with access to certain preventive items and services. MA prior authorization criteria A proposed rule implementing 2026 policy and technical changes for…
A nearly $3 billion settlement with Blue Cross Blue Shield leaves providers with a big choice (updated)
Note: The second section of this article was updated Dec. 5 with news that the proposed settlement has been formally approved. Providers that contract with Blue Cross Blue Shield should assess whether they want to participate in a landmark class-action settlement over litigation stemming from complaints about the insurer’s business practices. In October, a resolution…
New CMS bundled payment initiative may be the future of Medicare
CMS's Transforming Episode Accountability Model (TEAM) is a new bundled payment model that aims to move Medicare beneficiaries into value-based care arrangements by 2030, and hospitals participating in the model will be financially responsible for the cost and quality of care for five procedures.
Medicare, Medicaid are set to cover GLP-1 drugs under a Biden administration proposal
In a major development for Medicare and Medicaid, the Biden administration has issued a proposal for the program to cover a class of weight-loss drugs that have become increasingly prevalent in society. A proposed rule implementing Medicare Advantage and Medicare Part D technical and policy changes for 2026 includes a provision to reinterpret statutory language…
CY 2025 Home Health Prospective Payment System Final Rule Summary
HFMA presents a detailed summary of the final rule published by CMS updating the Home Health Prospective Payment System rates for home health agencies, disposable negative pressure wound therapy devices, and intravenous immune globulin items and services for calendar year 2025.
CY 2025 Physician Fee Schedule Final Rule Summary Part III – Quality Payment Program Updates
HFMA presents part III of three detailed summaries of the final rule relating to the Medicare physician fee schedule for CY 2025 and other revisions to Medicare Part B policies.
Biden’s director of Medicaid expresses concern for the program’s future amid talk of block grants
In what amounted to a valedictory for CMS leadership as it has been constituted during the Biden administration, the head of Medicaid expressed concern about the potential for big changes to the program. Daniel Tsai, director of the Center for Medicaid and CHIP services, said the possible transformation to a block-grant program under the incoming…
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…