CMS exclusion authority brings new fraud enforcement questions for providers
HHS’s decision to grant CMS exclusion authority creates a new enforcement consideration for healthcare providers participating in federal programs. HHS Secretary Robert F. Kennedy Jr. announced the update during a July news conference, and an Oct. 14 regulatory notice formalized the change, effective immediately. The notice gives CMS permissive exclusion authority under the Social Security…
FTC expands healthcare price transparency enforcement as HHS updates rules
Notable government actions on healthcare price transparency have taken place this week, with the Federal Trade Commission (FTC) opening a new front in enforcement of hospital price transparency and HHS updating regulations for health plans. Although hospital price transparency enforcement has primarily fallen under the purview of CMS, the FTC says breaches of transparency requirements…
MultiPlan antitrust litigation gains momentum after rulings for providers
Healthcare providers obtained two favorable rulings over the last month in their massive antitrust litigation against a vendor’s repricing algorithm. The case entails allegations that MultiPlan — which since has rebranded as Claritev — conspired to set out-of-network (OON) payment rates by gathering competitively sensitive information from roughly 700 health plans and using that information…
House bill would increase tax-exempt hospital reporting requirements
A bill that advanced out of a House committee Wednesday would add significant reporting requirements for tax-exempt hospitals. As passed by the Ways and Means Committee, the Tax-Exempt Hospital Transparency Act includes increased reporting obligations in areas such as community benefit, charity care, the 340B Drug Pricing Program and service-line spending. Requirements would be more…
DOJ’s OhioHealth antitrust settlement affects payer contracts
The U.S. Department of Justice and OhioHealth have settled antitrust litigation that hinged on allegations concerning the health system’s contracting practices. A June 16 filing with the Southern District of Ohio federal court states that the parties, which also include the state of Ohio, reached a consent decree in which OhioHealth does not admit wrongdoing…
Prevent denials by catching credentialing issues
Verifying the credentials of ordering physicians should be an essential part of revenue cycle management, and it could prove to be a fruitful endeavor. Ximena Restrepo, compliance and privacy partner for Billings Clinic–Logan Health, which serves residents of Montana and Wyoming, said Billings-Logan has saved thousands of dollars in avoided claim denials or in avoided…
States overhaul certificate-of-need laws
States have advanced a range of reforms to their certificate-of-need (CON) laws amid federal pressure to weaken or eliminate them. The highest-profile change, so far this year, was Tennessee’s April 16 passage of a bill (SB1369) to repeal its CON requirements for acute care hospitals. CON requirements for most acute care hospitals in the state…
Big financial impacts from off-campus HOPD rule change
Many hospitals and health systems are facing costly work in preparation for 2028 documentation requirements to avoid off-campus HOPD revenue losses. And some could see a big financial hit, even if they successfully meet those requirements. The Consolidated Appropriations Act of 2026, enacted Feb. 3, created new documentation requirements for off-campus hospital outpatient departments (HOPDs).…
Hospitals not yet a fraud focus
The Trump administration has ramped up high-profile healthcare fraud prevention efforts across a range of areas. Hospitals are not yet in the crosshairs. Ryan Thurber, an attorney with Polsinelli, said the focus of much of the administration’s healthcare and Medicaid fraud detection is on “nontraditional providers” of services around the periphery of healthcare, such as…
Operational resilience is the revenue cycle management imperative of the OBBBA era
The One Big Beautiful Bill Act (OBBBA) has altered Medicaid eligibility in ways hospitals can no longer treat as a background policy issue. Reverification of Medicaid coverage now happens so frequently that patients lose coverage for administrative reasons that have nothing to do with whether they actually qualify. Much of the industry dialogue has centered…