Policy Updates

Providers Faring Well in Surprisingly Busy Dispute Resolution Process

Health care providers are winning more than three-quarters of all payment disputes being brought through an unexpectedly active federal Independent Dispute Resolution process. The process, created under the 2020 No Surprises Act to settle payment disagreements between providers and payers and to spare consumers surprise medical bills – especially for receiving emergency care from providers outside of their insurer’s network.  2023 saw 13 times more disputes during the first half of 2023 – nearly 300,000 cases in all – than federal officials anticipated. With more than 20 percent of the disputes submitted for resolution rejected as ineligible for the process, [...]

2024-02-20T21:23:48+00:00February 21, 2024|Uncategorized|

Proposal Would Establish New “Essential Health System” Designation

The newly proposed “Reinforcing Essential Health Systems for Communities Act” would create a new federal hospital designation that would create a mechanism for directing more federal resources to safety-net hospitals that care for more low-income and uninsured patients. The bipartisan bill, sponsored by Representatives Lori Trahan (D-MA) and David Valadao (R-CA), would, according to Rep. Trahan, … provide federal lawmakers with the avenues necessary to target funding and resources to these critical facilities – just as we’ve done with other types of hospitals that serve specific populations or regions. Hospitals would qualify for “essential health system” status by meeting one [...]

Hospitals Rally Against Medicare Site-Neutral Payments

A proposal to save Medicare nearly $4 billion over a decade is running into stiff opposition. From hospitals. – and some members of Congress. Medicare has long paid more for outpatient services provided in hospital-based outpatient departments than it has for the same services delivered in private doctors’ offices.  Critics say this is unfair, that Medicare should pay the same no matter where the service is provided.  Defenders of the practice maintain that hospital-based outpatient departments share higher fixed costs, including for ERs and care for uninsured patients.  They also argue that reducing such Medicare outpatient payments could threaten the [...]

2024-02-15T13:42:15+00:00February 16, 2024|Medicare, Medicare reimbursement policy|

Federal Health Policy Update for February 15

The following is the latest health policy news from the federal government for February 9-15.  Some of the language used below is taken directly from government documents. Department of Health and Human Services HHS has released a 2023 update of its Equity Action Plan.  The plan outlines five priority areas to advance equity:  prevent neglect and improve care to help children thrive in their families and communities; promote accessible and welcoming health care for all; improve maternal health outcomes for rural, racial, and ethnic minority communities; prioritize the behavioral health of underserved populations; and increase clinical research and trial diversity [...]

Looming Medicaid Challenges

State Medicaid programs are facing significant financial challenges in the coming years. Among them:  less federal Medicaid matching money, a continued call by providers for increased payments, and a growing demand to use Medicaid to help address behavioral health challenges. In addition, proponents of investing more Medicaid money in home- and community-based services can be expected to ask state Medicaid programs to cover more services while those programs face a growing demand to use Medicaid resources to address social determinants of health such as poor housing and hunger. At the same time, large numbers of individuals continue to fall off [...]

No Surprises Act Implementation Yields Mixed Results

Is the No Surprises Act working?  Is it protecting patients from surprise medical bills?  Are providers and insurers happy? The Washington Post reports mixed results. On one hand, millions of people have been protected from surprise medical bills. But on the other hand… Experts thought that once the terms of the program were understood there would be only about 22,000 cases sent to arbitration – the law’s Independent Dispute Resolution process – in 2022.  Instead, nearly 500,000 cases went that route, with nearly half of the requests for arbitration coming from physician staffing companies owned by private equity firms.  At [...]

2024-02-14T16:33:47+00:00February 14, 2024|Uncategorized|

States Not Depending on Federal Action on Prior Authorization

Unwilling to leave the challenge of addressing the troubling prior authorization practices of many health insurers, officials in some states are trying to take matters into their own hands. Last year, lawmakers in 29 states considered 90 different bills to impose varying prior authorization requirements on health insurers serving their constituents.  Among the changes these proposals seek:  shorter response times for requests for authorization and mandatory public reporting of insurers’ prior authorization activity.  In addition, last year five states required insurers to engage in a practice known as gold carding:  waiving prior authorization for requested items and services for individual [...]

2024-02-13T16:56:53+00:00February 14, 2024|Uncategorized|

Millions Dropped From Medicaid Rolls

With the two-year “Medicaid unwinding” process nearly half complete, 9.5 million Americans have lost their Medicaid coverage – among them more than 3.7 million children. To date, 48 million of the 71 million people enrolled in Medicaid at pandemic’s end have had their eligibility reviewed.  So far, many of those who were at first ruled ineligible were dropped for procedural reasons, such as failing to file paperwork on time, but many of those people eventually had their benefits restored. Still, estimates that 15 million people would lose their Medicaid eligibility by the time the process ended appear to be overlying [...]

2024-02-08T22:22:10+00:00February 13, 2024|Medicaid|

CMS Clarifies Medicare Advantage Rule

To help clarify its final Medicare Advantage rule for 2024, the Centers for Medicare & Medicaid Services has published an FAQ providing additional guidance to Medicare Advantage plans and Medicare-Medicaid plans about prior authorization for admission to post-acute-care facilities and plans’ future use of artificial intelligence (AI), algorithms, and other software tools in their coverage criteria and utilization management practices. The rule has broad implications for most health care providers but especially for post-acute-care providers, which the FAQ reflects by addressing major issues and long-running challenges for such providers, including prior authorization for discharge from acute-care hospitals into post-acute care, [...]

Federal Health Policy Update for February 8

The following is the latest health policy news from the federal government for February 2 - 8.  Some of the language used below is taken directly from government documents. Congress Members of the Senate’s 340B bipartisan working group have released a discussion draft of legislation that would update the 340B prescription drug discount program.  Last year the group sought stakeholder input on policy solutions that might provide stability and transparency to the 340B program to ensure that the program can continue to achieve its original intent of supporting entities serving eligible patients.  Find a news release describing the discussion draft [...]

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