Payment Reimbursement and Managed Care

Hospitals push back against a coordinated effort to revamp the 340B program

A lobbying fight has started over the future of the 340B Drug Pricing Program, with hospitals seeking to protect what they view as an essential source of cost savings. The advocacy group 340B Health and prominent hospital associations are seeking to repel an effort led by the Pharmaceutical Research and Manufacturers of America (PhRMA) to…

Nick Hut March 23, 2023

New guidance for No Surprises Act arbitration looks like an improvement for providers

Responding to a recent court ruling, the U.S. Department of Health and Human Services (HHS) has updated the application of criteria for deciding No Surprises Act (NSA) independent dispute resolution (IDR) cases. Certified IDR entities (i.e., arbitrators) received guidance March 17 instructing them to more directly consider multiple factors when deciding on an out-of-network payment…

Nick Hut March 20, 2023

Here comes the Medicaid unwinding: The healthcare industry braces for coverage disruptions

A potentially tumultuous period for revenue cycle teams in particular and the U.S. healthcare system in general begins April 1, with the phasing out of a three-year run of Medicaid continuous enrollment. The so-called Medicaid “unwinding” originally was connected to end of the COVID-19 public health emergency (PHE), which is scheduled for May 11. But…

Nick Hut March 15, 2023

Affordability of healthcare is not enhanced when providers form health systems, studies find

The efficiencies gained when providers operate as a health system don’t always translate to care that is more cost-effective, according to two recently published JAMA studies on pricing. In one study, researchers with Harvard Medical School and the National Bureau of Economic Research (NBER) examined 2018 data from various sources, including CMS administrative data, IRS…

Nick Hut March 1, 2023

In federal ACO programs, advocates see signs of slow but steady progress

Growth in accountable care organization (ACO) programs has been inconsistent since the Affordable Care Act made accountable care part of the healthcare lexicon in 2010. Nonetheless, proponents are optimistic about the state of ACOs and their potential in upcoming years, even if there’s uncertainty about CMS’s ability to achieve its stated goal of ensuring every…

Nick Hut February 23, 2023

(Updated 2) Texas court again backs providers in No Surprises Act independent dispute resolution litigation

A physician association continues to roil the No Surprises Act’s arbitration process through successful litigation. For the second time in a year, the Texas Medical Association (TMA) prevailed in court after arguing that regulations governing the independent dispute resolution (IDR) process do not comply with legislative intent. Barring a successful appeal, the Feb. 6 ruling…

Nick Hut February 8, 2023

News Briefs: 2023 brings a steep fee hike for No Surprises Act arbitration cases

The No Surprises Act’s independent dispute resolution (IDR) process has become more expensive for healthcare stakeholders. For the new year, the nonrefundable administrative fee due from each party involved in any payment dispute that goes to arbitration increased from $50 to $350, according to a Dec. 23 memo from CMS’s Center for Consumer Information and…

Nick Hut January 27, 2023

Key points to know in recently proposed rules for Medicare Advantage and the ACA marketplaces

A proposed rule for health plans in Medicare Advantage has provisions designed to stem overreach in prior authorization processes.

Nick Hut January 20, 2023

Seeking to phase out Medicare DSH payments, MedPAC outlines potential changes to reimbursement for safety net providers

Revamped formulas for hospitals and physicians would be designed to better target payments to providers that treat larger shares of low-income Medicare beneficiaries.

Nick Hut January 18, 2023

Remedies for 340B underpayments remain up in the air after court declines to provide guidance

A federal court is allowing HHS to decide on remedies covering Medicare underpayments to hospitals for 340B drugs.

Nick Hut January 11, 2023
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