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…
Site-neutral payment debate intensifies in hospital affordability hearing
Site-neutral payment is at the forefront of the debate on policy levers to enhance affordability in the hospital industry, as indicated during a congressional hearing Tuesday. The House Ways and Means Committee hosted a panel of hospital CEOs, seeking insights on ways to tamp down spending on hospital care. Prices in the sector have risen…
ACA marketplace constraints reduce hospital revenue, shift payer mix
Coverage changes in government healthcare programs are starting to show up in hospital financials, based on Q1 reporting from the for-profit hospital sector. Most notably, 2026 cutbacks in Affordable Care Act (ACA) marketplace coverage are manifesting in lower revenues, while hospitals are getting a taste of what’s to come next year in Medicaid coverage. In…
CMS proposes electronic prior authorization for drugs
Amid ongoing implementation of federally required electronic prior authorization for healthcare items and services, CMS now proposes to do the same for pharmaceuticals. New regulations would apply to drugs under both medical and pharmacy benefits, according to a proposed rule published April 14. Faxes and payer portals for drug authorizations would be phased out in…
Hospital margins decline in 2026 as expenses outpace revenue
As hospitals seek to shore up their finances in a challenging environment, cost-focused initiatives are taking priority. “Organizations are saying, ‘We’ve got the revenue picture, [now] we’ve really got to get our expense picture to be sustainable with our revenue picture,’” said Steve Wasson, chief data and intelligence officer with Strata Decision Technology. “And what…
The Revenue Cycle of the Future: AI boom and workflow redesigns accelerate rev cycle transformation
Hospitals of all sizes are leveraging AI advancements and workflow redesigns to modernize revenue cycle management, aiming to lower costs, improve operational efficiency, and enhance the patient experience. While technology such as predictive analytics and automation shows promise in streamlining tasks, challenges remain in workforce adaptation, skill shifts, and the need for strategic collaboration, as leaders work to balance innovation with employee training and retention in an increasingly tech-driven environment.
Out-of-network pricing lawsuits test MultiPlan, Zelis business models
April 27 update Zelis provided a statement to HFMA regarding the lawsuit against the company’s out-of-network pricing model (see the original story below). “Last month’s decision was procedural and does not change Zelis’s position,” a company spokesperson said. “Zelis operates with a strong commitment to integrity, transparency and full compliance with all applicable laws and…
Medicare payment policy changes for 2027: Key signals from Kennedy hearings
Amid ample rancor, some of the rhetoric during congressional appearances Thursday by HHS Secretary Robert F. Kennedy Jr. had substantive implications for healthcare industry stakeholders. During two House hearings to discuss his department’s proposed FY27 budget, Kennedy and members of the Ways and Means Committee and a subpanel of the Appropriations Committee touched on a…
H-1B visa fee strains the healthcare workforce and hospital finances
In the year after implementation of a new White House policy curtailing the pipeline for legal immigration, the healthcare industry is grappling with the implications. In September, the Trump administration announced that the H-1B visa program for skilled workers seeking to enter the U.S. would carry a $100,000 fee per application. Healthcare, along with higher…
Predict, prevent, perform: The AI evolution of denials management
Healthcare providers continue to face escalating denial rates that erode financial performance and operational capacity. In 2025, denial rates averaged near 12%, with many organizations experiencing even higher volumes — each percentage point representing millions of dollars tied up in unresolved claims. The growing volume and complexity of denials are no longer manageable with legacy,…