What You Should Know:
- The Centers for Medicare & Medicaid Services (CMS) launches its Cell and Gene Therapy (CGT) Access Model, a new approach to delivering cutting-edge treatments for people on Medicaid living with sickle cell disease.
- A total of 33 states, plus the District of Columbia and Puerto Rico, will participate in this model, collectively representing approximately 84% of Medicaid beneficiaries with the condition, significantly expanding access to
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Healthcare Policy Regulation & Reform | News, Analysis, Insights - HIT Consultant
New Strategies Needed: No Surprises Act and the Challenges for Payors with Provider Data Inaccuracies
With more than 20 years of experience at a major health insurance company, I’ve seen firsthand how challenging provider data management can be. I’ve worked with teams reconciling files from delegated groups, fielded calls from frustrated providers, and navigated compliance pitfalls that can quickly become operational headaches. But the stakes have never been higher than they are now under the No Surprises Act (NSA).
For years, maintaining an accurate provider directory was considered a best
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Boost Medicare Star Ratings: A Strategic Game Plan for Health Plans
As they navigate complex times, health insurers have their eye on two important financial indicators. And both are moving in the wrong direction. Costs are on the rise while Medicare Star Ratings are on the decline.
Separate but related, the two trends converge on the same idea: health plans need to enable higher quality care at a lower price.
If it sounds like a Herculean feat, that’s because it is. But some health plans are making it happen.
While some of the cost pressures—for
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CMS Proposes 2026 Physician Fee Schedule Rule: Boosting Primary Care, Cutting Waste, and Modernizing Payments
What You Should Know:
- The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for the Calendar Year (CY) 2026 Medicare Physician Fee Schedule (PFS).
- The proposal aims to increase quality care for Medicare recipients while significantly reducing unnecessary spending. Key initiatives include advancing primary care management through new quality measures, reducing waste in skin substitute spending, and introducing a new payment model focused on
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HHS Reverses 1998 PRWORA Interpretation: Tightens “Federal Public Benefit” Access for Illegal Aliens
What You Should Know:
- The U.S. Department of Health and Human Services (HHS) today announced a significant policy shift aimed at restoring compliance with federal law and ensuring that taxpayer-funded program benefits, originally intended for American citizens, are not diverted to subsidize illegal aliens.
- HHS has formally rescinded a 1998 interpretation of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), which it states improperly
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Aledade Expands Michigan Footprint with Acquisition of CCA’s Value-Based Care Operations
What You Should Know:
- Aledade, the largest network of independent primary care in the United States, has announced its acquisition of the Michigan-based value-based care operations of CCA Holding Company, Inc.
- The move deepens Aledade’s presence across the state and empowers more physicians to succeed in a healthcare system focused on patient outcomes and quality.
Strengthening a Statewide Presence
The acquisition includes an Accountable Care Organization (ACO) and a
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Fighting the Chronic Disease Crisis with AI and Value-Based Care
Poorly managed and uncontrolled chronic diseases are the leading cause of death and disability in the United States, and represent a growing national crisis. Five of the top 10 causes of death – heart disease, cancer, diabetes, obesity, and hypertension – are chronic conditions, or closely linked to preventable and treatable chronic conditions. The prevalence of these diseases has steadily increased over the past two decades. Today, 42% of Americans have two or more chronic conditions, and the
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Healthcare Providers Face Over $770B Revenue Loss Under House Bill, Potentially Exceeding $1 Trillion with ACA Credit Expiration, Report Warns
What You Should Know:
- A new analysis from the Urban Institute, supported by the Robert Wood Johnson Foundation, projects that U.S. healthcare providers could lose more than $770B in revenue over the next decade if a budget reconciliation bill recently passed by the House of Representatives becomes law.
- The financial blow would stem from an estimated 11 million people losing health coverage through Medicaid and the Affordable Care Act (ACA) marketplaces. The report further
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Critical Role of Transitions of Care in Medicare Advantage Success
The Medicare Advantage (MA) market is at a tipping point, with more than half of all seniors enrolled in an MA plan for their healthcare. Utilization of services is skyrocketing and the Centers for Medicare and Medicaid Services (CMS) has increased pressure to deliver supplemental benefits in a high-quality, low-cost and reportable manner.
As enrollment continues to grow, how health plans are paid — and how much —will be central to the debate over the efficiency and sustainability of
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Inaccurate Provider Data: The Biggest Obstacle to Value-Based Care
Just months into office, the new administration is doggedly focused on reducing costs and increasing efficiency and transparency across a swath of functions. However, like many journeys, an emphasis is being placed on the final destination and not on how to navigate the road ahead. Even so, expect value-based care (VBC) to move from the back to the front burner and the heat to get turned up.
VBC is a business model for healthcare in which providers are paid based on the quality of care
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