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
May 11 update Developments since publication of this article include CMS’s announcement that implementation of electronic prior authorization would be added to the pledges taken by participants in the Health Tech Ecosystem. The ecosystem is a public-private partnership launched in 2025 to establish a nationwide digital healthcare infrastructure that improves data interoperability and empowers patients…
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,…
CMS FY27 rule expands bundled payments, adjusts Medicare inpatient reimbursement rate
For the first time, a value-based payment model is set to become mandatory for almost all hospitals nationwide. The expansion of the Comprehensive Care for Joint Replacement (CJR) bundled payment model is a headlining provision of the newly released Medicare FY27 proposed rule for hospital inpatient services and long-term care hospitals (LTCHs). Also in the…
In a first, a drugmaker’s lawsuit challenges HRSA’s 340B patient definition
In a new chapter for litigation involving the 340B Drug Pricing Program, a drugmaker is suing the federal government over the definition of patient as it pertains to the program. AbbVie Inc. says the definition established by the Health Resources and Services Administration (HRSA) in 30-year-old guidance is unwieldy and enables inappropriate access to 340B…