Earlier this year the Centers for Medicare and Medicaid Services introduced the "Wasteful and Inappropriate Service Reduction" model, a series of prior authorization requirements designed to ensure timely and appropriate Medicare payment for select items and services in six states (New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington) that take effect Jan. 1.
As part of the “WISeR” requirements, CMS selected tech vendors to implement enhanced technological models to
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Healthcare Policy Regulation & Reform | News, Analysis, Insights - HIT Consultant
Cornell Survey: Experts Warn HSA Conversion and Small Premiums Threaten ACA Affordability
What You Should Know:
- A new survey from the Cornell Health Policy Center reveals that 70% of health policy scholars believe converting ACA subsidies into Health Savings Accounts (HSAs) would worsen affordability for enrollees.
- Additionally, 81% of experts agree that ending automatic renewals—a policy slated for 2028 under the "One Big Beautiful Bill Act"—will substantially reduce Marketplace enrollment. These findings come as policymakers scramble to find alternatives to enhanced
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Why Rural Health Transformation Must Include Maternal Health
Congress’ most recent budget reconciliation bill included controversial cuts to Medicaid spending. The legislation slashed hundreds of billions of dollars from the program over the next decade, a move that is likely to disproportionately affect rural hospitals and safety-net providers.
To offset the cuts, lawmakers introduced the $50 billion Rural Health Transformation Program (RHTP), a five-year initiative (2026-30) meant to
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The VBC Paradox: Why Hospitals Are Doubling Down on Value-Based Care While Revenue at Risk Lags
What You Should Know:
- A new report from Sage Growth Partners reveals a striking disconnect in the healthcare industry: while only 20% of C-suite leaders believe progress has been made in value-based care (VBC) recently, 77% plan to increase their participation in these models over the next two years.
- The "plot twist" indicates that despite operational hurdles and low revenue exposure today, hospital executives view VBC as essential for long-term financial survival. The data
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The $4,000 Deductible Era: Why Employer-Sponsored Insurance is Breaking the American Worker
What You Should Know:
- A new 50-state analysis reveals that over half (51.7%) of U.S. private-sector workers are now enrolled in high-deductible health plans (HDHPs) as employers struggle to manage rising costs. The report shows that annual family premiums jumped to $24,540 in 2024, outpacing inflation, while average family deductibles surpassed $4,000 for the first time.
- The trend exposes millions of Americans to greater financial risk in medical emergencies, signaling a
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Beyond Stereotypes: 3 Ways Empathetic Outreach Can Drive Medicaid Member Engagement and Retention Post-OBBA
Connecting with Medicaid members has never been so challenging—or so crucial—as the system faces great uncertainty in light of the recently passed One Big Beautiful Bill Act.
Finding inroads that resonate with members can be difficult as this diverse segment faces plenty of barriers to care that also inhibit meaningful connections. Non-medical social drivers of health, such as lack of transportation, food and housing insecurities, and even basic health literacy can get in the way of
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ACOs Must Lead on Specialty Care to Control Costs
Both the greatest strength and weakness of the ACO shared savings (MSSP) model is its focus on primary care, particularly chronic disease. ACOs have put patients with diabetes, hypertension, and other conditions usually handled through primary care physicians at the center of care coordination, population health, and care management. But as CMS Value-Based Care’s central goal has shifted to cost control, ACOs will need to broaden scope to optimize specialty care. TEAM (Transforming Episode
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CMS Notifies 742 Hospitals of Pricing Targets for New Value-Based Payment Model
What You Should Know:
- On November 15, 2025, the Centers for Medicare and Medicaid Services (CMS) will begin notifying 742 hospitals and health systems of their 2026 pricing targets and quality scores for the Transforming Episode Accountability Model (TEAM).
- CMS issued a final rule in July codifying the TEAM model, which aims to reduce costs and improve the quality of outcomes for millions of Americans.
TEAM Model
The model focuses on the five highest-spend surgical
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Reinventing Value-Based Care Program Administration with AI
Implementing a new VBC program in healthcare requires cross-functional support and overcoming numerous challenges. Simplification opportunities exist to address pain points for program administrators such as rigorous research, ROI assessment, and stakeholder engagement. Manual processes, including participant recruitment, financial modeling, program integrity management, and technical assistance can benefit from technology to streamline and automate tasks, allowing skilled resources to focus on
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Demystifying Prepay Coordination of Benefits: A Crucial Component of Payment Integrity
Coordination of benefits (COB) is a key component of any effective payment integrity program. But determining primacy for members with multiple plans and ensuring claims aren’t overpaid can be a complicated process. Whether it’s verifying employment status or sifting through complicated claims, COB takes significant time for peak accuracy. And while health plans focus on the intricacies of an effective COB strategy, many overlook the possibilities that a comprehensive prepay COB solution can
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