Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Federal Regulation

CMS Proposed Rule Aims to Secure 2018 Risk Adjustment Payments

August 13, 2018 - CMS has proposed a new rule that aims to resolve legal issues over the risk adjustment program’s payment methodology.  The rule would ensure that payers will receive appropriate risk adjustment payments for plan year 2018. The proposed rule will implement CMS’s statewide premium methodology to calculate payment rates and provides a clarifying statement on how the 2018...


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Provider Market Concentration Outweighs Payer Concentration

by Thomas Beaton

Healthcare provider systems tend to be bigger, more consolidated, and have more market share than payers in the same metropolitan areas, leaving some payers with less power to negotiate pricing and other contracts, according to the...

CMS Final Rule Extends Short-Term Health Insurance to 3 Year Max

by Thomas Beaton

CMS has issued a final rule that triples the length of time a beneficiary can keep short-term health insurance. The rule allows individuals to purchase a new short-term, limited benefit health plan that lasts for 12 months, or extend...

CMS Approves Wisconsin State Reinsurance Program

by Thomas Beaton

CMS has approved Wisconsin’s plan to launch a state reinsurance program from 2019 to 2023 to help reduce individual state premiums and control the growth of state healthcare spending. The program, called the Wisconsin Healthcare...

12 Attorneys General File Lawsuit Over Association Health Plans

by Thomas Beaton

A dozen state attorneys general are suing the Department of Labor (DOL) over the expansion of association health plan (AHPs).   In the suit, which was filed in the DC District Court of Appeals, the officials argue that broad...

CMS Proposes Site-Neutral Payments, Drug Price Negotiation

by Thomas Beaton

CMS has proposed a rule that would expand the use of site-neutral payments and improve the drug price negotiation process with manufacturers in order to reduce Medicare’s overall spending. The new rule would allow Medicare to...

CMS Proposed Rule Cuts State Authority to Divert Medicaid Payments

by Thomas Beaton

CMS has proposed a new rule that would eliminate a state’s authority to divert Medicaid payments away from providers. The rule is intended to ensure beneficiaries have adequate access to healthcare services through direct...

Transitional Health Insurance Plays Key Role in Coverage

by Thomas Beaton

Transitional health insurance, otherwise known as a short-term health plan, is a temporary insurance policy intended to provide stop-gap coverage when an individual is in between ACA compliant policies.  The National Association of...

CMS Suspends $10.4B in Risk Adjustment Payments to Payers

by Thomas Beaton

CMS has temporarily withheld $10.4 billion in risk adjustment payments for 654 healthcare payers, citing a ruling in the US District Court of New Mexico that invalidated the agency’s risk adjustment methodology. The ruling, which...

Vermont Government Plans Regulations for Association Health Plans

by Thomas Beaton

Vermont’s Department of Financial Regulation (DFR) is planning to implement emergency rules and regulations for association health plans (AHPs) following the Department of Labor’s final rule to allow AHP sales nationally. DFR...

CMS: Individual Health Plan, Federal Exchange Challenges Remain

by Thomas Beaton

CMS has released three new reports indicating that the individual health plan and federal exchange markets faltered somewhat in 2017 because of increasing premiums, decreasing competition, and stagnant enrollment. The agency believes that...

DOJ Nabs 601 Defendants in Biggest Healthcare Fraud Takedown Yet

by Thomas Beaton

HHS Secretary Alex Azar and Attorney General Jeff Sessions have announced the largest healthcare fraud takedown yet after HHS, the Department of Justice (DOJ), and other law enforcement agencies charged 601 healthcare professionals for $2...

Federal Court Strikes KY 1115 Medicaid Waiver Work Requirements

by Thomas Beaton

The US District Court for the District of Columbia has blocked Kentucky from implementing work requirements within its 1115 Medicaid waiver demonstration, despite CMS approval of the community engagement provisions. The court ruled that...

CMS Approves Okla. Value-Based Drug Purchasing for Medicaid

by Thomas Beaton

CMS has approved the nation’s first value-based drug purchasing agreement for Medicaid by allowing Oklahoma’s state program to negotiate supplemental prescription drug rebates based on treatment outcomes. CMS allows state...

CMS to Develop New Medicaid Program Integrity Initiatives

by Thomas Beaton

CMS has announced a new set of Medicaid program integrity initiatives that leverage enhanced data sharing, claims auditing, and provider education to reduce the incidence of improper payments and help secure program finances. In 2016,...

Senators: Stop $89B in Medicare, Medicaid Improper Payments

by Thomas Beaton

The US Senate Budget Committee has penned a letter to HHS Secretary Alex Azar urging the department to address approximately $89 billion in improper payments within Medicare and Medicaid. The Senators referenced a recent GAO report...

Department of Labor Finalizes Association Health Plan Expansion

by Thomas Beaton

The Department of Labor (DOL) has issued a final rule that expands consumer availability of association health plans (AHPs) starting on September 1, 2018. The rule comes months after President Trump and the DOL proposed executive changes...

US Court: Payers Are Responsible for Risk Corridor Program Costs

by Thomas Beaton

Federal judges in the US Federal Circuit Court of Appeals have issued an opinion stating that healthcare payers, and not HHS, are responsible for the costs of the ACA’s risk corridor program. Chief Judge Sharon Prost filed the...

BlueCross BlueShield Nets $2.3B in Savings from 2017 Tax Cuts

by Thomas Beaton

BlueCross BlueShield companies saw  a total tax savings of $2.3 billion after passage of last year’s Tax Cuts and Jobs Act (TCJA), according to a new creditor’s briefing from AM Best. BCBS companies reported a mix of...

Humana, Roche Diagnostics Face $45M Federal Kickback Lawsuit

by Thomas Beaton

Humana and Roche Diagnostics will face a $45 million federal kickback lawsuit after a whistleblower filed a False Claims Act violation, which alleges Roche tried to entice Humana financially to secure access to the payer’s business...

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