Finalized appeals processes for Medicare patients will require new hospital protocols in 2025
Hospitals should prepare to imminently accommodate new appeals processes and paperwork for 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 CMS…
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…
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…
OPPS APC/HCPCS Lookup Tool
HFMA presents a spreadsheet allowing the user to pull-up basic descriptive and payment information for OPPS APC/HCPS codes.
Susan Dentzer: It is time to move past denying the perfect storm facing U.S. healthcare
The healthcare sector is facing a perfect storm of aging patients, rising costs, aging providers, and a shortage of primary care physicians, creating a need to a shift toward preventive care, increased use of technology, more virtual and home care and sustainable care teams.
New rules have program integrity implications for Medicare, Medicaid stakeholders
CMS in recent days issued a pair of final rules designed to improve aspects of program integrity in Medicare and Medicaid. The Medicare rule was published Sept. 27 and finalized proposals that were published in early July after CMS became aware of significant potential billing fraud involving a specific type of urinary catheter. Premier, Inc.,…
Comparison of Proposed 2025 OPPS Addendum B with July 2024 Addendum B
HFMA presents a spreadsheet comparing relative weights and payment rates at the HCPCS level, using proposed rule Addendum B compared to 2024 Addendum B.
Comparison of Proposed 2025 OPPS Addendum A with July 2024 Addendum A
HFMA presents a spreadsheet comparing relative weights and payment rates at the APC level, using the 2025 proposed rule Addendum A, compared to 2024 Addendum A.
How to respond to Medicare Advantage’s rising headwinds
In recent years, the Medicare Advantage (MA) program has enjoyed rapid membership growth. About 33 million Americans — or 54% of all Medicare-eligible individuals — are currently enrolled in MA, according to a recent Kaiser Family Foundation analysis.a For providers and payers that participate in MA, success is predicated on facilitating a virtuous cycle: a…
MedPAC starts to scrutinize the costs of outpatient coinsurance at critical access hospitals
At the nation’s nearly 1,400 critical access hospitals (CAHs), cost-sharing payments incurred by Medicare beneficiaries for outpatient services are onerous enough that a new methodology warrants consideration, according to a recent policy discussion. The Medicare Payment Advisory Commission (MedPAC) examined the issue at its September meeting, reporting that beneficiary coinsurance for CAH outpatient care equates…