Providers’ winning streak in No Surprises Act QPA litigation ends as appeals court overturns a prior ruling
Healthcare providers incurred a rare defeat in litigation over a key facet of the No Surprises Act, with an appeals court ruling that the original methodology for calculating the qualifying payment amount (QPA) is permissible. The Oct. 30 decision restores language from prior regulations and means insurers can continue to incorporate or exclude certain disputed…
Report suggests the extent to which Medicare Advantage health plans are skirting the two-midnight rule
As hospitals struggle with payer tactics involving denials, a new analysis quantifies the extent to which Medicare Advantage (MA) health plans still avoid paying for inpatient care. The report by Kodiak Solutions examined claims data from more than 1,900 hospitals and found that MA plans categorized hospital visits as outpatient observation stays at a rate…
Providers can expect UnitedHealthcare to undertake closer inspection of coding patterns
Healthcare spending that exceeded expectations is motivating UnitedHealthcare to take a more rigorous look at provider coding practices. For two consecutive quarters, parent company UnitedHealth Group (UHG) has reported that the medical-cost ratio (MCR) of UnitedHealthcare is being impacted by several factors. One is provider coding trends, the company’s leaders said during investor calls. “In…
Bridging the payer-provider divide
No one wins when there is animosity between health plans and healthcare providers, least of all patients. They often must wait months to find out whether care will be covered and what their out-of-pocket cost will be as payers and providers negotiate the details.
Purchased services are a mystery worth solving
Hospitals and health systems have made significant strides in supply purchasing. Supplies typically go through a standard purchase order process, are easily benchmarked and, at many organizations, have been centralized to take advantage of bulk, leveraged and consolidated discount opportunities. In contrast, purchased services are typically characterized as follows. Fragmented. They are typically not centralized…
Finalized appeals processes for Medicare patients will require new hospital protocols in 2025 (updated)
Hospitals should prepare to imminently accommodate new appeals processes and paperwork for some Medicare patients whose status gets changed from inpatient to outpatient observation during a stay. A newly published final rule gives beneficiaries options for appealing such a change. The effective date of the new appeals processes was not announced in the rule, but…
Providers hope to reverse a court’s No Surprises Act ruling that would affect independent dispute resolution
Hospital and physician advocates are urging an appeals court to reverse a district court’s decision that would render No Surprises Act (NSA) arbitration payments unenforceable. In May, two air ambulance companies lost a case in a Northern District of Texas federal court in which they sought payment from Health Care Service Corporation (HCSC) for awards…
Hospital price transparency enforcement should look at pricing data quality, GAO says
In a report on federal oversight of hospital price transparency regulations, the Government Accountability Office (GAO) says CMS should expand its enforcement purview. The report rehashes many of the technical and formatting issues that stakeholders have discussed since the regulations took effect in 2021. But it goes a step further by questioning whether guardrails are…
Despite positive outcomes, coverage of GLP-1 drugs presents complicated questions
The drugs known as GLP-1 receptor agonists bring the potential for improved health to millions but also a bevy of questions and challenges concerning cost and coverage, according to insights in a recent webinar. GLP-1s such as Ozempic and Wegovy initially came to market as a way to control blood sugar for people with type…
5 revenue cycle management myths dispelled
The traditional healthcare revenue cycle was designed to evolve around payer reimbursement. Processes and workflows were pretty much set in stone. Step 1: register the patient; step 2: verify insurance and eligibility; step 3: capture the charges; step 4: code the claim, and so on. The lack of automation and interoperability solutions, especially electronic health…