Payment Reimbursement and Managed Care

Why the Medicare physician fee schedule is sheer madness 

Amid the complexities of U.S. healthcare, there is probably no construct that’s more byzantine than the Medicare Physician Fee Schedule (MPFS) — the program’s elaborate system of paying physicians and other clinicians (including nurse practitioners, physician assistants and clinical psychologists) for more than 10,000 medical services.a In 2022, the schedule drove about $71.2 billion in…

Susan Dentzer, MS April 30, 2024

A new 340B dispute resolution process could create more opportunities for providers

Regulatory updates to the administrative dispute resolution (ADR) process in the 340B Drug Pricing Program seem likely to expedite the filing of claims over manufacturers’ refusal to offer discounts on drugs distributed at contract pharmacies. HHS and the Health Resources and Services Administration (HRSA), which administers the 340B program, published a final rule that modifies…

Nick Hut April 26, 2024

FY 2025 Inpatient Rehabilitation Facility PPS Proposed Rule Summary

HFMA presents a detailed summary of the proposed rule published by CMS on the Medicare inpatient rehabilitation facility prospective payment system updates for FY 2025.

HFMA April 26, 2024

FY 2025 IPPS/LTCH PPS Proposed Rule Summary

HFMA presents a detailed summary of the FY 2025 IPPS/LTCH prospective payment system proposed rule, released by CMS on April 10, 2024.

HFMA April 22, 2024

How a health system goes above and beyond in its price transparency efforts

By maintaining a patient-centric perspective, hospitals and health systems can find opportunities to look beyond regulatory requirements and incorporate top-class price transparency models, according to a recent online discussion. “We want to, first and foremost, empower and equip our customers to make informed decisions about their healthcare services and really shop for the best value,”…

Nick Hut April 22, 2024

FY 2025 Hospice Payment Rate Update Proposed Rule Summary

HFMA provides a detailed summary of the proposed rule updating the Medicare hospice payment rates, wage index and Hospital Quality Reporting Program for FY 2025.

HFMA April 18, 2024

CMS calls for hospitals to be subject to a new bundled payment model and data-reporting requirements

Notable policies in Medicare’s FY25 proposed rule for inpatient hospital care and long-term care hospitals include the formation of a mandatory bundled payment model and requirements for hospital data reporting. Although the proposed payment rate was the headlining aspect of the rule for hospitals, the policy developments could have a longer-term impact on segments of…

Nick Hut April 16, 2024

The Medicaid unwinding continues to pose issues one year in, but healthcare coverage appears stable

The unwinding of Medicaid continuous-enrollment requirements reached the one-year mark this month amid mixed measures of the effect on overall coverage. In one sense, the impact has exceeded all projections. Since states could begin disenrolling Medicaid beneficiaries on April 1, 2023, coverage for more than 19.6 million beneficiaries had been terminated as of April 4,…

Nick Hut April 12, 2024

Hospital advocates bemoan the small Medicare payment increase proposed for FY25

The payment increase described in Medicare’s FY25 proposed rule for acute care and long-term care hospitals falls well short of what hospitals need to keep up with costs, advocates say. The payment rate would rise by 2.6% for hospitals that fulfill quality-reporting requirements and meet the criteria to be designated as meaningful users of electronic…

Nick Hut April 11, 2024

Insurers see reasons for concern as CMS keeps the Medicare Advantage purse strings tight for 2025

Medicare Advantage (MA) faces the prospect of constrained revenue and payments for participating stakeholders after CMS finalized what amounts to a small decrease in the 2025 payment rate. Average revenue for MA plans is projected to increase by 3.7%, or more than $16 billion — but that’s primarily because of a prospective increase in the…

Nick Hut April 4, 2024
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