340B lawsuits against CVS allege $250M in underpaid hospital reimbursement
CVS Health’s pharmacy benefit manager (PBM) under-reimbursed three health systems by almost $250 million over five years in connection with the 340B Drug Pricing Program, according to new lawsuits. Filed in three separate federal courts, the complaints describe how CVS Health and its subsidiaries retained a large share of the savings generated through the 340B…
CMS moves to curb MA plans’ unfair payment advantage
In April, CMS published its annual Medicare Advantage (MA) rate announcement for 2027.a For most years in recent memory, this would be a routine event, accompanied by no small amount of headshaking from the provider community. Hospitals and physicians would be perpetually perplexed at why CMS would give MA plans generous payment increases, while giving hospitals…
Off-campus outpatient billing rules could extend to commercial claims
Hospitals preparing for new off-campus outpatient department (OPD) billing requirements in Medicare may soon face a parallel mandate for commercial claims. The House Education and Workforce Committee on May 21 unanimously passed the Transparency in Billing Act, which would prohibit commercial health plans from paying claims that do not include a unique identifier for the…
CMS’s Medicaid state-directed payment rule would expand limits beyond hospitals
CMS’s proposed rule on Medicaid state-directed payments (SDPs) would implement limits authorized by the One Big Beautiful Bill Act (OBBBA) while applying restrictions to a broader swath of Medicaid, including certain fee-for-service (FFS) supplemental payments. Essentially, the agency issued proposed regulations that would take some of the OBBBA’s Medicaid provisions a step further. Services previously…
The hospital of the future, with Jeni Williams
Erika Grotto talks with HFMA senior editor Jeni Williams about her new special report, Hospital of the Future. Nick Hut talks with Kathy Stull, HFMA’s senior manager of revenue cycle analytics about prior authorization. More: CMS Interoperability and Prior Authorization Final Rule CMS-0057-F | CMS 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed…
Healthcare reimbursement: Succeeding under value-based and FFS payment
Healthcare reimbursement — payment for care and services delivered — plays a key role in a hospital’s overall financial performance and organizational stability. There are many different types of reimbursement models, from fee-for-service to value-based payment and shared savings. Typically, a hospital operates under a variety of different reimbursement models according to the contracts it…
ACA marketplace final rule could add to payer-mix concerns for providers
In new regulations setting coverage parameters for Affordable Care Act (ACA) marketplace health plans, CMS is attempting to intertwine increased program integrity with greater flexibility for states and insurers. The balancing act is part of an effort to fortify the marketplaces in a year when enrollment already has fallen by more than 1 million after…
GLP-1 coverage costs pressure employers and Medicare plans in 2026
Even as evidence accumulates about the efficacy of GLP-1 drugs, concerns surrounding insurance coverage of the products remain unresolved. Both employers and insurers are trying to navigate the dichotomy between clinical benefits and potentially burdensome costs. “Against the backdrop of anticipated double-digit healthcare cost increases, fueled to a large degree by GLP-1s and overall prescription…
States and hospitals prepare for new administrative tasks as Medicaid work requirements loom
Efforts by states to implement the Medicaid work requirement are intensifying, with hospitals likely to play a supporting administrative role when the requirement begins nationwide Jan. 1, 2027, based on findings in a new report. As legislated in the One Big Beautiful Bill Act (OBBBA), adults in the Medicaid expansion population must demonstrate that they…
PAMA laboratory data reporting requirements for hospitals are set to impact Medicare lab payments
Hospitals offering clinical diagnostic laboratory services should take note of imminent reporting obligations that will affect Medicare payment rates. Reporting of commercial final-paid claim rates as the basis for Medicare rate setting was included in the Protecting Access to Medicare Act of 2014 (PAMA) and initially took place in 2017. Subsequent phases of data reporting…