Healthcare reimbursement: Succeeding under value-based and FFS payment
Healthcare reimbursement — payment for care and services delivered — plays a key role in a hospital’s overall financial performance and organizational stability. There are many different types of reimbursement models, from fee-for-service to value-based payment and shared savings. Typically, a hospital operates under a variety of different reimbursement models according to the contracts it…
ACA marketplace final rule could add to payer-mix concerns for providers
In new regulations setting coverage parameters for Affordable Care Act (ACA) marketplace health plans, CMS is attempting to intertwine increased program integrity with greater flexibility for states and insurers. The balancing act is part of an effort to fortify the marketplaces in a year when enrollment already has fallen by more than 1 million after…
GLP-1 coverage costs pressure employers and Medicare plans in 2026
Even as evidence accumulates about the efficacy of GLP-1 drugs, concerns surrounding insurance coverage of the products remain unresolved. Both employers and insurers are trying to navigate the dichotomy between clinical benefits and potentially burdensome costs. “Against the backdrop of anticipated double-digit healthcare cost increases, fueled to a large degree by GLP-1s and overall prescription…
States and hospitals prepare for new administrative tasks as Medicaid work requirements loom
Efforts by states to implement the Medicaid work requirement are intensifying, with hospitals likely to play a supporting administrative role when the requirement begins nationwide Jan. 1, 2027, based on findings in a new report. As legislated in the One Big Beautiful Bill Act (OBBBA), adults in the Medicaid expansion population must demonstrate that they…
PAMA laboratory data reporting requirements for hospitals are set to impact Medicare lab payments
Hospitals offering clinical diagnostic laboratory services should take note of imminent reporting obligations that will affect Medicare payment rates. Reporting of commercial final-paid claim rates as the basis for Medicare rate setting was included in the Protecting Access to Medicare Act of 2014 (PAMA) and initially took place in 2017. Subsequent phases of data reporting…
Interoperability Standards and Prior Authorization for Drugs Proposed Rule Summary
HFMA provides a detailed summary of the proposed rule intended to improve the electronic exchange of health care data and streamline processes related to prior authorization by increasing the interoperability of systems used across the health care industry.
Site-neutral payment debate intensifies in hospital affordability hearing
Site-neutral payment is at the forefront of the debate on policy levers to enhance affordability in the hospital industry, as indicated during a congressional hearing Tuesday. The House Ways and Means Committee hosted a panel of hospital CEOs, seeking insights on ways to tamp down spending on hospital care. Prices in the sector have risen…
ACA marketplace constraints reduce hospital revenue, shift payer mix
Coverage changes in government healthcare programs are starting to show up in hospital financials, based on Q1 reporting from the for-profit hospital sector. Most notably, 2026 cutbacks in Affordable Care Act (ACA) marketplace coverage are manifesting in lower revenues, while hospitals are getting a taste of what’s to come next year in Medicaid coverage. In…
FY 2027 IPPS/LTCH PPS Proposed Rule Summary
HFMA presents a detailed summary of the FY 2027 Medicare inpatient prospective payment system and long-term care hospital prospective payment system proposed rule published in the Federal Register on April 14, 2026.
CMS proposes electronic prior authorization for drugs
May 11 update Developments since publication of this article include CMS’s announcement that implementation of electronic prior authorization would be added to the pledges taken by participants in the Health Tech Ecosystem. The ecosystem is a public-private partnership launched in 2025 to establish a nationwide digital healthcare infrastructure that improves data interoperability and empowers patients…