The WISeR prior authorization model for Medicare is set to pose challenges for hospitals
Hospitals and other healthcare providers soon will have a larger set of prior authorization requirements to account for in traditional Medicare as a new pilot model gets underway. Technology companies participating in the six-year, six-state Wasteful and Inappropriate Service Reduction (WISeR) Model are supposed to have their portals up and running by Jan. 5, with…
Elevance Health rebuffs providers’ calls to cancel a contentious out-of-network payment policy
Healthcare providers in 11 states face the imminent possibility of payment reductions from a top subsidiary of Elevance Health, one of the nation’s largest insurers. Anthem Blue Cross and Blue Shield announced this quarter that it would apply a 10% penalty to the allowed amount on commercial insurance claims when hospital care is provided by…
CMS plans to bar hospitals from Medicare and Medicaid participation for providing gender-affirming care to minors
Hospitals would face significant financial consequences for providing gender-affirming care as treatment for minors who have gender dysphoria, according to a newly proposed rule from CMS. Specifically, any hospital offering care such as puberty blockers, hormone therapy and surgery to minors would be locked out of Medicare and Medicaid, the agency said in announcing formal…
Texas hospitals fall short in an appellate ruling about disproportionate share hospital payment calculations
An appeals court dealt hospitals a defeat in a case about Medicare disproportionate share hospital (DSH) payments, reversing a lower court’s prior ruling on jurisdictional grounds last week. A Dec. 9 decision by a three-judge panel at the U.S. Court of Appeals for the Fifth Circuit means certain Section 1115 waiver days can remain excluded…
MedPAC finds the hospital industry is on a more stable financial footing now
Hospitals do not need a Medicare payment boost for 2027 beyond the update to be provided in the statutory formula, says the Medicare Payment Advisory Commission (MedPAC). Whereas the commission had recommended that Congress increase hospital payments by an additional 1% or 1.5% ahead of each year from 2024 through 2026, the recommendation for 2027…
Questions loom over the future of telehealth policy
Federal telehealth policy continues to prove confounding for healthcare providers. The recent 43-day government shutdown marked the first extended period since the early days of the COVID-19 pandemic that traditional restrictions on telehealth reimbursement were in place. Medicare waivers of those restrictions helped telehealth utilization surge during the pandemic and remain elevated in the years…
At the 11th hour, an Affordable Care Act subsidy accord remains elusive (updated Dec. 12)
Dec. 18 update The only year-end healthcare legislation to pass at least one chamber of Congress does not include an extension of the Affordable Care Act (ACA) enhanced subsidies, but members have not given up on reaching an agreement in early 2026. House Republicans passed a bill Dec. 17 that includes provisions (see the Dec.…
Hospitals hope litigation will stop the 340B rebate model before it gets started
Hospitals are going to court in an effort to thwart major changes to the 340B Drug Pricing Program. The American Hospital Association (AHA) was among a group that filed a lawsuit against the federal government Dec. 1, seeking to have implementation of a planned 340B rebate model halted before it begins Jan. 1. Under the…
CMS’s latest transparency rule aims to make price estimates more specific
Hospitals face additional and potentially more demanding price transparency reporting requirements in 2026, as finalized in new CMS regulations. The final rule for hospital outpatient departments and ambulatory surgical centers includes provisions building off the current transparency regulations. The new language is intended to ensure that hospitals “provide meaningful, accurate information about the amount they…
2026 Medicare final rule postpones a significant payment cut for hospitals
While implementing several policies that could constrain hospital finances next year and beyond, CMS offered temporary relief on one count. The Medicare 2026 final rule for hospital outpatient departments and ambulatory surgical centers (ASCs) was proposed to include an across-the-board 2% cut to base payments. But CMS, acknowledging the concerns of hospitals, kept the scheduled…