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Charting the Course: Leading Hospitals Through CMMI’s Seismic Shift  February 19, 11:00 AM PSTWith shifting regulations and increasing technical complexity, hospitals and health systems face constant pressure to maintain compliance. In this session, Vice President of...
WISeR (Wasteful and Inappropriate Service Reduction) Model November 2025 Overview CMS has the responsibility to protect the Medicare Trust Funds, and routinely analyzes data associated with all facets of the Medicare program. A 2020 analysis of claims submitted by...
CMS 4201 Final Rule: Empowering Providers Against MA Denials Originally Posted on Becker's Hospital ReviewNavigating the ever-changing landscape of healthcare management, providers find themselves in an intricate dance with Medicare Advantage Organizations (MAOs)....
Overview In a late 2021 legislative session, Congressional activity resulted in a little bit of breathing room for hospitals after the New Year. In a bipartisan vote by Senate late last week, legislation was passed that mitigates nearly 10% Medicare reimbursement cuts...
There is still a lot of confusion regarding the impact on Medicare beneficiaries from eliminating the Inpatient-Only List. As recent as last week, an article from The Washington Post titled New cost-cutting Medicare rule may add costs to patients, discussed how this...
These waivers, known as 1135 waivers (due to being granted by Section 1135 of the Social Security Act), are allowed when 2 conditions are met: First, there must be a declaration of a Public Health Emergency (PHE) by the Secretary of the Department of Health and Human...
Five hospital outpatient department (OPD) services will require prior authorization when provided on or after July 1, 2020. These services include: Blepharoplasty Botulinum toxin injections Panniculectomy Rhinoplasty Vein ablation What is prior authorization as it...
Since the onset of the 2-midnight rule, hospitals have been spared the onslaught of medical necessity denials from Recovery Audit Contractors (RACs). The RACs have certainly branched into other areas of audit in hospitals, but tightened claim limits have significantly...
OIG Raises Concerns About Service and Payment Denials Under Medicare Advantage Plans According to CMS, almost 37% of all Medicare beneficiaries will enroll in Medicare Advantage plans in 2019. In addition, the market remains very attractive to insurers who plan to...
Over the last few years, there has been a trend toward automating the medical necessity UR screening process using software to extract clinical data and either apply commercial criteria or create an acuity score. As I have strolled across trade show floors, I see...
Charting the Course: Leading Hospitals Through CMMI’s Seismic Shift  February 19, 11:00 AM PSTWith shifting regulations and increasing technical complexity, hospitals and health systems face constant pressure to maintain compliance. In this session, Vice President of...
WISeR (Wasteful and Inappropriate Service Reduction) Model November 2025 Overview CMS has the responsibility to protect the Medicare Trust Funds, and routinely analyzes data associated with all facets of the Medicare program. A 2020 analysis of claims submitted by...
CMS 4201 Final Rule: Empowering Providers Against MA Denials Originally Posted on Becker's Hospital ReviewNavigating the ever-changing landscape of healthcare management, providers find themselves in an intricate dance with Medicare Advantage Organizations (MAOs)....
Overview In a late 2021 legislative session, Congressional activity resulted in a little bit of breathing room for hospitals after the New Year. In a bipartisan vote by Senate late last week, legislation was passed that mitigates nearly 10% Medicare reimbursement cuts...
There is still a lot of confusion regarding the impact on Medicare beneficiaries from eliminating the Inpatient-Only List. As recent as last week, an article from The Washington Post titled New cost-cutting Medicare rule may add costs to patients, discussed how this...
These waivers, known as 1135 waivers (due to being granted by Section 1135 of the Social Security Act), are allowed when 2 conditions are met: First, there must be a declaration of a Public Health Emergency (PHE) by the Secretary of the Department of Health and Human...
Five hospital outpatient department (OPD) services will require prior authorization when provided on or after July 1, 2020. These services include: Blepharoplasty Botulinum toxin injections Panniculectomy Rhinoplasty Vein ablation What is prior authorization as it...
Since the onset of the 2-midnight rule, hospitals have been spared the onslaught of medical necessity denials from Recovery Audit Contractors (RACs). The RACs have certainly branched into other areas of audit in hospitals, but tightened claim limits have significantly...
OIG Raises Concerns About Service and Payment Denials Under Medicare Advantage Plans According to CMS, almost 37% of all Medicare beneficiaries will enroll in Medicare Advantage plans in 2019. In addition, the market remains very attractive to insurers who plan to...
Over the last few years, there has been a trend toward automating the medical necessity UR screening process using software to extract clinical data and either apply commercial criteria or create an acuity score. As I have strolled across trade show floors, I see...
Root Cause to Revenue: Winning the Battle Against DRG Downgrades 07.29.2026 11:00 AM PT Executive Vice President Vice President, Denials Management ServicesHospitals and health systems face mounting revenue challenges from denials to evolving payer tactics, making...
CMS Contract Year 2027 Medicare Advantage Final Rule Updates (CMS-4208-F3/CMS-4212-F) Overview On April 2, 2026, CMS released the Contract Year 2027 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare...
Hospitals Race to Keep Pace as Payers and AI Reshape Denials Hospitals Race to Keep Pace as Payers and AI Reshape Denials Denials have become one of the defining pressure points in healthcare finance. Across hospitals and health systems, claims teams are balancing...
