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…
New federal rule means big changes in coverage of behavioral healthcare
Landmark regulations issued by the Biden administration are intended to establish coverage parity for behavioral healthcare services. A newly published final rule prohibits group health plans, along with health insurers offering group or individual insurance coverage, from restricting access to mental-health and substance-use disorder (SUD) benefits as compared with medical and surgical benefits. The rule,…
Information Blocking Disincentives for Certain Health Care Providers Final Rule Summary
HFMA presents a detailed summary of the final rule establishing disincentives for certain Medicare-enrolled health care providers and suppliers that are found to have committed information blocking.