Report quantifies the financial impact of certain health plan business practices on providers
As hospitals seek to regain their financial footing coming out of the pandemic, they may find themselves stymied by commercial payer policies, according to a new report. “It’s true that commercial payers might generate more net revenue than public payers on a per-case basis,” Crowe states in a report it recently published. “But at what…
News Briefs: The expiration of the COVID-19 PHE brings an end to key provisions
The termination of the COVID-19 public health emergency (PHE) on May 11 meant providers lost many of the accommodations and regulatory flexibilities that were in place since Jan. 31, 2020. For example, Medicare’s 20% add-on payment for treating COVID-19 cases in the inpatient setting no longer is available. With reported cases and hospitalizations steadily trending…
The state of Medicare Advantage: As the program grows, healthcare stakeholders express concerns
As seen during a recent virtual conference, the accelerating expansion of Medicare Advantage (MA) has been accompanied by tension over growing pains such as regulatory issues. “I think MA was set up really well, but like anything else there’s sort of a moment where you have to look at the program and say: How do…
New data on No Surprises Act arbitration cases show providers are faring well amid systemic challenges
Providers are having success at challenging out-of-network payment amounts under the No Surprises Act, at least when they can get their cases through the arbitration system. CMS published an update showing that between April 15, 2022, when the independent dispute resolution (IDR) portal opened, and March 31, arbitrators issued payment determinations in 42,158 disputes. Initiating…
News Briefs: Medicare’s proposed FY24 update to inpatient payments falls short, hospitals say
Hospitals are less than pleased with Medicare’s proposed FY24 payment increase for inpatient care. In regulations released April 10, the net inpatient payment update is 2.8% after factoring in a mandatory productivity adjustment of -0.2 percentage points. As usual, the update would be reduced for any hospital that does not fulfill quality-reporting requirements or qualify…
Final rule for Affordable Care Act marketplace plans could expand contracting opportunities for certain types of providers in 2024
Final 2024 regulations for health plans participating in the Affordable Care Act (ACA) insurance marketplaces are designed to improve equitable access to behavioral healthcare, potentially meaning a wider array of providers will have a chance to be included in networks. As of 2023, a participating plan must have at least 35% of available essential community…
Healthcare News of Note: What can be done to correct data disparities in women’s health?
The prevalence of women’s health conditions is roughly five times that of their documented diagnoses, which means for every woman diagnosed with a women’s health condition, roughly four go undiagnosed. The 2023 emergency medicine Match will see 555 initially unmatched positions, affecting a larger number of residency programs than in 2022, when 219 unmatched positions…
CMS and other stakeholders take steps to improve prior authorization in Medicare Advantage and beyond
Several recent developments point to an industrywide effort to ease the burden of prior authorization. Most notably, CMS on April 5 finalized a rule that includes provisions designed to improve prior authorization in Medicare Advantage (MA) starting with the 2024 plan year. The rule addresses a few aspects of prior authorization, among them the way…
Court decision means cost sharing could be reinstated for some preventive healthcare services
Comprehensive coverage of some preventive care services could be jeopardized by a recent court ruling. Since its passage, the Affordable Care Act (ACA) had required health plans to cover the full cost of services that received an “A” or “B” rating from the U.S. Preventive Services Task Force (USPSTF). A federal judge in Texas ended…
New guidance for No Surprises Act arbitration looks like an improvement for providers
Responding to a recent court ruling, the U.S. Department of Health and Human Services (HHS) has updated the application of criteria for deciding No Surprises Act (NSA) independent dispute resolution (IDR) cases. Certified IDR entities (i.e., arbitrators) received guidance March 17 instructing them to more directly consider multiple factors when deciding on an out-of-network payment…