340B claims data requirements put hospital discounts under stress
Provider advocates criticized Eli Lilly for ramping up pressure on hospitals to comply with a new policy regarding claims submission in the 340B Drug Pricing Program. The drug manufacturer said holdout hospitals will lose 340B discounts on all Lilly products unless the hospitals quickly comply with a mandate issued earlier this year to submit claims…
Medicaid work requirement rule adds significant wrinkles to program eligibility criteria
For state agencies and potentially healthcare providers, CMS’s regulatory guidance on implementing the Medicaid work requirement imposes responsibilities that go beyond language seen in the underlying statute. CMS published an interim final rule with comment period late Monday, just barely meeting the June 1 deadline established in the 2025 reconciliation law known as the One…
Healthcare affordability and financial sustainability concerns test CFO strategy
Healthcare stakeholders can implement strategies that improve both affordability for consumers and financial sustainability for providers, according to insights from a recent panel discussion. The effort should start with “making sure that we understand what this balance is of financial sustainability of the institution and affordability for the patients, for the consumers, for the communities…
Final rule lowers No Surprises Act IDR fees, adds requirements
Regulations issued Thursday to update the No Surprises Act’s independent dispute resolution (IDR) process represent an effort to improve access while also streamlining the volume of cases. CMS and the Departments of Labor and Treasury published a final rule that significantly lowers IDR fees but includes more requirements of the insurers and providers that seek to use…
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…
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…
Healthcare compliance risks rise as CMS expands fraud enforcement
With recent developments highlighting the Trump administration’s emphasis on healthcare fraud prevention, providers should ensure their compliance processes are working optimally. The administration has taken various steps in 2026, including this month. On May 13, CMS announced it was withholding $1.3 billion in Medicaid funding from California. During media availability at the White House that…
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…
Healthcare price transparency is heading for a more consequential phase
Key developments loom for healthcare price transparency both legislatively and in the private sector, according to insights from a recent congressional hearing. Sen. Bill Cassidy (R-La.), who is a physician and an influential healthcare policymaker in Congress, conducted a field hearing May 5 with stakeholders in his home state to examine the issue of healthcare…