Elevance Health brings commercial site-neutral payment to hospital claims
Elevance Health is moving site-neutral payment concepts into commercial reimbursement, with a Sept. 29 announcement setting the stage for constraints on hospital payment. The insurer said it would incorporate a series of new billing policies “intended to address increasingly common situations where care provided at an off-campus location is billed at a higher hospital rate.”…
Value-based care and alternative payment models: What they are and how they work
Value-based care (VBC) is an approach to healthcare that seeks to improve the quality, outcomes and experience of care while managing its cost. Rather than rewarding healthcare organizations solely for the volume of services they provide, value-based arrangements link some or all payment to measures of quality, outcomes, utilization or total cost of care. The…
James Mathews: Why site-neutral payment does not mean eliminating the IPO list
During my tenure at the Medicare Payment Advisory Commission (MedPAC), the Commission recommended that Medicare implement site-neutral payment for certain services and procedures in defined circumstances. The premise was sound at the time, but ideas about this approach have evolved in recent years — to the point that it may have led CMS to the…
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.…
CMS cites ACA marketplace enrollment fraud in issuing 760,000 coverage cancellations
CMS has canceled roughly 315,000 enrollments encompassing 760,000 people in Affordable Care Act (ACA) marketplace plans, citing suspected fraud, according to a Sept. 22 announcement by the Trump administration. And the numbers soon could grow. The administration also plans to commence verification of legal residency, Social Security numbers, and income and other eligibility criteria for…
2027 Medicare lab fee schedule points to 15% cuts across many test codes
Preliminary data for the 2027 Clinical Laboratory Fee Schedule (CLFS) indicate substantial downward pressure on Medicare reimbursement for lab services. CMS released information on the 2027 payment rates ahead of final rates expected in November, projecting that the methodology used to set the rates would save $1 billion annually for Medicare. Hospital-based and freestanding labs…
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.
CMS’s ACCESS Model expansion adds chronic care tracks for Medicare providers
CMS continues to put weight behind the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model, a 10-year initiative to apply value-based payment and digital solutions to chronic disease management. The agency announced Sept. 15 that it would add to the services covered under the model. Newly covered conditions effective April 1, 2027, are set…
Texas Medicaid hospital funding gap grows amid CMS delays on FY27 approvals
Sept. 18 Update Texas Gov. Greg Abbott announced Sept. 17 that CMS had agreed to allocate nearly $12 billion in Medicaid supplemental payments to the state’s healthcare providers, ending the impasse over FY27 state-directed payments (SDPs). Included in the sum is $9.15 billion for hospitals, which the Texas Hospital Association (THA) estimated were losing $27…
2027 Medicare primary care payment changes target longstanding undervaluation
Medicare payment for primary care is set to undergo noteworthy changes in 2027, with bigger updates looming. The proposed rule for Medicare’s Physician Fee Schedule (PFS) includes provisions to address what CMS recognizes as a long-running undervaluation of primary care, according to an agency leader. “We’re embarking on a two-year strategy to change that,” Jake…