Health system PBM ownership model shows benefits amid reform pressure
Amid heightened scrutiny of the pharmacy benefit manager (PBM) model, one health system is touting an alternative approach. St. Louis-based SSM Health is co-owner of Navitus Health Solutions, a PBM with 18 million members among 800 clients across all 50 states. Navitus has a niche that helps it optimally serve customers while bolstering the operation…
CMS’s claims attachments rule sets deadline to shift to full electronic submission
New administrative standards from CMS give providers two years to prepare to submit all claims-related documentation electronically. The agency issued a final rule to create the first HIPAA-adopted national standards for the electronic exchange of supporting clinical documentation. A primary goal of the new regulations is to phase out manual processes among both providers and…
MedPAC says hospital payments are sufficient, urges better safety-net targeting
Medicare payment to hospitals is broadly adequate but should be better targeted for lower-resourced facilities, according to a formal recommendation by the Medicare Payment Advisory Commission (MedPAC). In its annual report to Congress on Medicare payment policy, MedPAC said 2027 inpatient and outpatient payments should increase in accordance with the statutory formula and do not…
Hospitals targeted in healthcare affordability debate on Capitol Hill
Large employers are looking to put much of the impetus for improving healthcare affordability on hospitals, according to congressional testimony Wednesday. “Many of the biggest cost increases are driven by hospitals and health systems and can be addressed today,” Elizabeth Mitchell, president and CEO of the large-employer coalition Purchaser Business Group on Health (PBGH), said…
Panel: AI can improve prior authorization in healthcare but won’t solve all the issues
New approaches to prior authorization are crucial to improve a process that remains essential to supporting healthcare quality, according to a subject matter expert. “Prior auth exists because there’s a bell curve of care in the United States,” said Jeremy Friese, MD, founder and CEO of Humata Health, referring to substantial variability “from a safety…
CMS details implementation of Medicaid 6-month eligibility checks under the OBBBA
CMS has issued guidance on how Medicaid expansion states should implement the higher-frequency eligibility redeterminations as required under the One Big Beautiful Bill Act (OBBBA). Starting in 2027, states must conduct eligibility checks of most adults in the expansion population every six months, up from annually (the guidance refers to the 2025 law as the…
Hospitals urged to strengthen cybersecurity amid rising Iran-linked threats
March 16 update During the week of March 9, the Michigan-based medical equipment manufacturer Stryker reported being hit by a cyberattack. Per various news reports, the attack was perpetrated by a hacking group linked to Iran. The company says operations ranging from manufacturing to processing and shipping are being impacted, but products in the field…
Hospitals can use 2026 to prepare for CMS TEAM bundled payment risk
In what amounts to a dress-rehearsal year, hospitals participating in CMS’s mandatory Transforming Episode Accountability Model (TEAM) should take the opportunity to prepare for the high stakes that loom. TEAM, a five-year bundled payment model that is obligatory for nearly 750 hospitals in 188 selected markets, is upside-only in its first year. The ante rises…
Medicare claims processing modernization gains urgency at CMS
In 2025, the newly created U.S. Department of Government Efficiency (DOGE) was associated with the large-scale culling of staff and a proposed restructuring at HHS, along with substantial reductions in personnel at many other departments. These days, in addition to releasing a massive file of provider-level Medicaid billing data, DOGE is placing its healthcare focus…
How to use an enterprise approach in implementing AI in RCM
Revenue cycle transformation has long been framed as a matter of technological advances. But in the AI-fueled era, the differentiator is shifting from individual technologies to enterprise operating model redesign, according to leaders from Mayo Clinic and Jefferson Health. They described how their organizations are repositioning revenue cycle as a core component of care delivery,…