Implementing AI in Risk Adjustment for Managed Care is like adding rocket fuel to your engine—from accelerating chart reviews to identifying coding opportunities in near real-time, AI can dramatically improve efficiency, accuracy, and compliance. But without the right safeguards, the same tools can just as easily magnify errors, introduce bias, and create costly regulatory exposure.
As Managed Care organizations navigate this rapidly evolving landscape, a key question looms: How
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Healthcare Policy Regulation & Reform | News, Analysis, Insights - HIT Consultant
ACA Spillovers: A Warning for Employers as Insurers Seek Up to 43% Premium Hikes
What You Should Know:
- The U.S. healthcare market is showing a stark divergence in cost trends between public and private sectors. While Affordable Care Act (ACA) premiums are spiking well above the industry's decade-long trend of sub-10% increases, real-world claims data from self-funded employers show costs holding steady at under 5%, according to new data from Nomi Health.
ACA Rate Hikes Driven by Utilization and Risk
ACA insurers across the country are filing for some
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CMS Launches $50B Rural Health Transformation Program
What You Should Know:
- Today, the Centers for Medicare & Medicaid Services (CMS) unveiled details for states to apply for funding from the new $50B Rural Health Transformation Program.
- Created under the Working Families Tax Cuts Act, this unprecedented investment is designed to strengthen healthcare across rural America and build sustainable systems that improve access, enhance quality of care, and improve outcomes for patients.
Five Strategic Goals for Rural
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Medicaid Expansion: A Guide for Healthcare Providers to Prepare for Change
Medicaid is a lifeline for roughly 84.5 million people across the U.S., yet access to that safety net still depends on state lines. Ten states—Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming—continue to reject the Affordable Care Act (ACA) expansion, leaving an estimated 1.4 million adults in the infamous coverage gap. This category includes individuals whose earnings are too high for traditional Medicaid but still below the poverty level
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HHS Terminates California’s PREP Grant Over Refusal to Remove Gender Ideology Content
What You Should Know:
- The U.S. Department of Health and Human Services (HHS), through its Administration for Children and Families (ACF), has terminated California’s Personal Responsibility Education Program (PREP) grant.
-The termination follows California’s refusal to remove "radical gender ideology" from the federally funded education program, which is designed to prevent teenage pregnancy and sexually transmitted infections.
Rejecting Mandate to Change Sex-Ed
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J.D. Power Study: Medicare Advantage Member Satisfaction Declines Amid Policy Changes
What You Should Know:
- A new report from J.D. Power reveals a significant decline in member satisfaction with Medicare Advantage (MA) plans. The J.D. Power 2025 U.S. Medicare Advantage Study reveals that satisfaction dropped to an average score of 623 out of 1,000, which is down 29 points from the previous year.
- According to the study, the primary cause for this decline is a 39-point drop in members' overall trust in their plans. This trend is occurring in the wake of significant
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Policy: CMS Launches New Oversight Initiative to Verify Medicaid and CHIP Eligibility
What You Should Know:
- The Centers for Medicare & Medicaid Services (CMS) has launched a new oversight initiative to ensure that enrollees in Medicaid and the Children’s Health Insurance Program (CHIP) are U.S. citizens, U.S. nationals, or have a satisfactory immigration status. The program aims to safeguard taxpayer dollars and protect these vital programs from abuse.
- CMS will provide states with monthly enrollment reports that identify individuals whose citizenship or
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HHS Repeals Policy Linking Hospital Reimbursement to Staff Vaccination Reporting
What You Should Know:
- Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. today announced the repeal of federal policy that financially rewarded hospitals for reporting staff vaccination rates, a policy he described as coercive and a denial of informed consent.
- “Medical decisions should be made based on one thing: the wellbeing of the person - never on a financial bonus or a government mandate,” said Secretary Kennedy. “Doctors deserve the freedom to use their
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CMS Finalizes TEAM Model: A New Era of Value-Based Surgical Care
What You Should Know:
- The Centers for Medicare & Medicaid Services (CMS) today issued the 2026 Final Rule that officially codifies the Transforming Episode Accountability Model (TEAM), an innovative new blueprint for tech-enabled, outcome-based care payment models.
- Starting in 2026, TEAM will hold hospitals and health systems accountable for the entire episode of care for major surgeries, from admission through 30 days post-discharge, with the goal of reducing
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Beyond Disruption: 4 Key Strategies for Healthcare Providers to Thrive Under OBBBA
What You Should Know:
- The U.S. healthcare landscape is facing a transformative moment with the signing of H.R. 1, the “One Big Beautiful Bill Act” (OBBBA), into law on July 4. This landmark legislation introduces sweeping changes to Medicaid and Medicare, as well as Affordable Care Act (ACA) subsidies.
- According to Tamyra Porter, Managing Director of Regulatory Advisory Practice at Premier, these shifts present both significant challenges and a rare inflection point for
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