CMS undertakes Medicare Worksheet S-12 audits of hospital cost reports
CMS is emphasizing hospital compliance with updated Medicare cost-reporting requirements, recently announcing an audit of first-year submissions of a brand-new worksheet. For cost-reporting periods ending on or after Jan. 1, 2026, most hospitals paid under the Inpatient Prospective Payment System have had to complete Worksheet S-12. Those submissions will be subject to auditing by a…
CMS proposes Medicare Advantage provider directory requirements for 2028
Medicare Advantage (MA) plans are set to face requirements aimed at improving the accuracy of provider directories, according to a proposed rule. Issued Oct. 16 by CMS, the proposed regulations would implement provisions of the Consolidated Appropriations Act of 2026 (CAA 2026). Beginning in 2028, new mandates applicable to network-based MA plans and certain private…
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…
340B rebate model lawsuit seeks to halt 2027 rollout, citing hospital costs
Oct. 12 Update Another potential challenge to the 340B rebate model is forming in Congress, where a bipartisan quartet in the House introduced the 340B Rebate Model Delay Act on Oct. 9. The legislation, which has not yet been posted, would delay the model until 2029 to give Congress more time to evaluate the financial…
CMS guidance details how states can apply the Medicaid medical frailty exemption
New guidance from CMS explains how states can operationalize the medical frailty exemption to the Medicaid work requirement. Per the guidance, the intent is for states to identify medically frail beneficiaries proactively through claims and other existing data to the degree possible, thereby alleviating the administrative burden and risk of coverage loss facing those beneficiaries.…
Compliance audit efficiency, a new learning experience from HFMA and updates on Medicaid eligibility
Erika Grotto talks with Dawn Crump from MRO about audit efficiency. Michael Grant, HFMA’s director of learning experience, discusses updates to HFMA’s learning platform. In the news segment, Nick Hut talks with HFMA policy director Katie Gilfillan about Medicaid eligibility updates.
How Medical Practices Can Protect Revenue Through Compliance
By integrating proactive compliance and strong revenue cycle management workflows, practices can ensure accurate documentation and secure reliable, timely reimbursement. Dive into this article to learn more.
OMB federal grant rule delayed as Congress passes continuing resolution
The continuing resolution (CR) passed by both houses of Congress ensures the federal government will remain fully operational into December, and it also freezes implementation of a noteworthy change to grant-approval processes. Until the CR’s Dec. 11 expiration date, the Office of Management and Budget (OMB) is blocked from finalizing a previously proposed rule regarding…
Court decisions on ACA marketplace rules affect key coverage provisions
As CMS moves ahead with Medicaid funding limits for gender-affirming care in minors, Democratic state leaders used litigation to block restrictions in the Affordable Care Act (ACA) insurance marketplaces. The ACA policy, established in 2025 regulations, would remove the essential health benefit (EHB) designation from gender-affirming care. EHB status allows ACA consumer protections, such as…
No Surprises Act QPA calculations set to change after appeals court ruling
An appeals court sided with providers in a case about the No Surprises Act’s qualifying payment amount (QPA), a key benchmark in out-of-network payment determinations. The U.S. Court of Appeals for the Fifth Circuit issued a ruling that QPA calculations must not include ghost rates, referring to non-negotiated rates listed in contracts for services a…