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…
Medicare Advantage 2027 payment update increases after a CMS revision
Belying earlier projections, CMS gave Medicare Advantage (MA) health plans a payment hike for 2027. Payments will increase by 2.48%, or more than $13 billion, according to a final rate notice published April 6. It’s a better outcome for stakeholders than was anticipated when CMS released the advance rate announcement in January. Then, the payment…
Trump’s FY27 HHS budget proposal outlines cuts, operational changes
President Donald Trump’s healthcare budget proposal for FY27 emphasizes Making America Healthy Again (MAHA) priorities and slashes operational costs within HHS. At $111.1 billion, total HHS funding would decrease by $15.8 billion, or $12.5%, relative to FY26. When counting onetime recissions, the effective cut would be nearly $23 billion (from $112.3 billion in FY26 to…
ACA marketplace enrollment declines as subsidies expire in 2026
CMS’s latest 2026 enrollment numbers for the Affordable Care Act (ACA) marketplaces indicate a relatively moderate drop-off from 2025, although the final tally could look notably different. The agency reported this week that 23.1 million were enrolled at the close of open enrollment for Healthcare.gov and the state-run marketplaces. That’s a 4.9% decline from 2025,…
DOJ brings antitrust lawsuits challenging hospital contracting practices
June 4 update NewYork-Presbyterian responded to the lawsuit brought by the U.S. Department of Justice alleging anticompetitive business practices in the organization’s contracting with insurers (see the original story below). The health system is arguing for a dismissal of the government’s case. Partially echoing OhioHealth’s defense against similar allegations, NYP said the contractual provisions at…
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
March 30 update CMS sent out an email announcing a town hall to discuss the new final rule. The town hall takes place Tuesday, March 31 between 1 p.m. and 2:30 p.m. Eastern time. No registration is required. The town hall can be joined at this Teams link. As there will not be a live…
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…