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November 13, 2026
CMS is offering states an optional six-month enforcement grace period for new Medicaid work requirements, allowing them to test and improve eligibility systems without denying or terminating otherwise eligible beneficiaries for noncompliance through June 30, 2027.
This article was originally published on Fierce Healthcare.
November 12, 2026
Over the past year, UnitedHealth Group has conducted a series of independent reviews of its practices as part of a broader turnaround effort at the company.
This article was originally published on Fierce Healthcare.
November 12, 2026
CMS and ONC are launching a voluntary industry testing initiative to help healthcare organizations prepare for federal electronic prior authorization requirements taking effect in 2027.
This article was originally published on Fierce Healthcare.
Author: Knicole C. Emanuel Esq. | November 12, 2026
The Centers for Medicare & Medicaid Services (CMS) finalized its Outpatient Prospective Payment System (OPPS) rule for the 2027 calendar year (CY).
At first glance, hospitals get a raise. Look more closely, though, and the rule takes back a large share with the other hand.
We’ll start with the good news.
Hospitals that meet quality reporting requirements will see a 2.3-percent payment update. That figure is a projected market basket increase of 3.2 percent, minus a 0.9-percentage-point productivity adjustment.
Overall, Medicare outpatient payments are projected to climb by $11 billion, to $114.4 billion. Ambulatory Surgical Centers (ASCs) get the same 2.3-percent bump, which comes to about $560 million more, for a total of $9.9 billion.
Now, the rest of the story.
340B: Round Two
Today, 340B hospitals are paid average sales price plus 6 percent for separately payable drugs. Under the Final Rule, that becomes average sales price minus 28 percent. That is a little gentler than the minus 33.4 percent CMS proposed, but it is still a steep drop. CMS expects to cut Medicare spending by $4.35 billion and beneficiary drug costs by $1.1 billion next year.
Around 2021, CMS cut 340B payments to average sales price minus 22.5 percent. In 2022, a unanimous U.S. Supreme Court struck those cuts down. The Court held that CMS could not set different rates for one group of hospitals without first conducting the acquisition cost survey the statute requires. That ruling cost the agency roughly $9 billion in repayments.
This time, CMS says it performed the survey, and that it found “substantial disparities” between what hospitals pay for 340B drugs and what they pay for other drugs. Critics are not convinced. The Association of American Medical Colleges calls it a “hasty and faulty survey” that fails to follow “the clear requirements of the Medicare statute.” Whether this version holds up in court is the question to watch.
There is also a clawback. Under budget neutrality rules, the original 340B cuts raised payments for non-drug services, and CMS is still recovering $7.8 billion of those increases. The Final Rule raises the annual offset from 0.5 percent to 2 percent, which puts full recovery on track for 2031. Hospitals are effectively paying for the last fight while the next one begins.
Site Neutrality and the Inpatient-Only List
Also, site-neutral payments are expanding to imaging without contrast, including certain bone density scans, X-rays, ultrasounds, CT scans, and MRIs performed in off-campus, provider-based departments. CMS projects savings of $260 million in 2027 and more than $9 billion over 10 years. Rural sole community hospitals are exempt.
Third, the phase-out of the Inpatient-Only List continues. CMS is removing 637 more services in 2027, and several hundred procedures are joining the ASC covered list. The direction is clear: care, and dollars, are moving out of the hospital.
Two Very Different Stories
CMS Administrator Dr. Mehmet Oz describes the rule as “right-sizing payments and rooting out waste.” The American Hospital Association (AHA) hears something else. It says the rule “does not adequately take into account the financial challenges facing hospitals today,” especially in rural and underserved communities. It also says outpatient departments treat “sicker and more complex” patients than independent practices do.
One Sleeper Provision
Finally, there is a provision compliance teams should not miss. Accrediting organizations with deeming authority may now assess the administrative Emergency Medical Treatment and Labor Act (EMTALA) requirements under 42 C.F.R. § 489.20. These include signage, the central emergency department log, five-year retention of transfer records, and on-call physician lists. Enforcement of the substantive patient protections in § 489.24 stays with CMS and the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). In practice, your next accreditation survey may include an EMTALA paperwork check.
The Bottom Line
The bottom line is a modest raise, a sizable 340B cut, a faster clawback, and a probable return to court. Hospitals should model the net effect now and keep their litigation options open.
This article was originally published on RACmonitor.
Author: Mary Inman, Esq. | November 12, 2026
Here’s a number that should get the attention of our audience: $166 million. That’s how much the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) says one hospital may have been overpaid from the COVID Provider Relief Fund.
Part of the reason is that somewhere in the process, $755 million in quarterly revenue apparently became $157,000. Let me explain.
Last week, HHS-OIG released a report on the COVID-era Provider Relief Fund program, which was designed to keep healthcare providers afloat as lockdowns caused non-emergency healthcare utilization to plummet. The last phase of the program paid out about $19.3 billion to roughly 64,000 providers.
Each payment to a provider under the program was calculated as the greater of 2 percent of the provider’s patient care revenue or 88 percent of its reported COVID losses. The figures those calculations were based on were generally self-reported.
For the audit, OIG pulled a random sample of 150 providers. Every one of them was eligible under the Provider Relief Fund Program. But 65, or over 43 percent of the sampled providers, received payments that were miscalculated, and 39 (or 26 percent of the sampled providers) were potentially overpaid – by a whopping $655 million.
Health Resources and Services Administration (HRSA), the agency that administered the program, received more than 100,000 applications for provider relief funds. For about 95 percent of them, no humans reviewed the supporting documents. Providers didn’t have to document what share of their revenue came from patient care, and sometimes it would be impossible to do so retroactively. When the contractor couldn’t tell whether an item was patient care, HRSA assumed it was.
In its audit, OIG found that providers sometimes counted capitation and certain pharmacy revenues as patient care. Expense figures reported by providers also sometimes included advertising, gifts, travel, and alcohol. In one instance, a corporation documented its numbers via an individual’s tax returns. In another, a medical group claimed revenue from three subsidiaries without listing them, so earlier relief payments to those subsidiaries never got deducted.
All in all, OIG’s review pointed to a host of different problems, including the possibility of fraud and a meaningful error rate in the money that was paid out.
If these errors were knowing or intentional, they could constitute False Claims Act (FCA) violations. The FCA is a law that allows private individuals, whistleblowers, to sue in the name of the government and share in any recovery.
The law applies to any area where the government does business, but these days, the majority of cases and money recovered come from healthcare.
Knowingly reporting false data to HRSA to get a larger check from provider relief funds would be an example of fraud. This would apply if a provider overstated past patient care revenues, miscategorized other revenues as patient care revenues, or exaggerated the extent of COVID-related losses. Many factual fraud schemes would fall into these scenarios.
To date, provider relief funds have not been a major area of False Claims Act settlements. But with numbers and error rates like these, that’s likely changing soon.
This article was originally published on RACmonitor.
Author: Timothy Powell, CPA, CHCP | November 11, 2026
Hospitals should treat artificial intelligence (AI) implementation as a change to an operating process, with a responsible manager and measurable results. For revenue-cycle leaders, success means accurate claims, defensible appeals, and appropriate collections after accounting for the full cost of the technology.
A federal analysis of hospital survey data found that, among hospitals using predictive AI, use for billing simplification or automation increased from 36 percent in 2023 to 61 percent in 2024. Those figures measure adoption, not proven savings, and concern predictive AI rather than generative AI alone.[1]
In KFF’s May 2026 interview, “AI at Scale: Does It Deliver?” HCA Healthcare’s Michael Schlosser emphasizes evaluating the outcomes produced by people working with AI. His account focuses on solving clinical and operational problems, involving users early, and monitoring performance after deployment.[2]
I would begin with one defined task, such as preparing appeal drafts for a particular denial category. Assign a revenue-cycle manager responsibility for the result, supported by compliance, information technology, and the employees doing the work. Record the current turnaround time, error rate, and cost before introducing the tool.
A UW Health study of AI implementation in outpatient documentation, published in NEJM AI in 2025, offers a concrete warning. An audit of 797 encounters across 17 providers identified a note template change associated with the study’s measure of diagnosis documentation accuracy falling from 79 percent to 35 percent. Redesign and training restored accuracy to approximately 80 percent. The authors traced the problem to the surrounding electronic record workflow, outside the core AI process.[3]
For revenue-cycle departments, that experience supports testing the complete path from source record to final claim or appeal. A correct recommendation has limited value if a missing diagnosis, incorrect account match, or broken interface changes what reaches the payer.
For an appeal assistant, verify that the tool receives the actual denial reason, the relevant claim, and the documentation supporting the requested payment. Require it to identify its evidence. A persuasive letter containing an invented clinical fact or an unsupported coverage argument creates additional risk.
Run the initial pilot alongside the existing process. Have qualified employees review outputs against the medical record and applicable payer requirements before submission. Record corrections and investigate their causes. Retest whenever templates, data feeds, or the AI application change.
Employees need time to practice, report errors, and learn when to escalate an uncertain result. Include difficult accounts in testing so the pilot reflects the department’s actual workload.
KFF’s April 2026 analysis of AI and health disparities emphasizes representative data and continued monitoring to address bias.[4] For a hospital, I would extend that principle to checking results across relevant patient groups, languages, service lines, and payer categories. An acceptable overall average can conceal recurring failures within a smaller group.
Before using patient information, establish approved data access, retention limits, vendor responsibilities, and a procedure for correcting errors. Give staff a clear route to pause a malfunctioning workflow.
The financial review should include integration, licenses, training, human review, and correction costs. Follow appeals through payment or final disposition; count legitimate collections and avoid treating every dollar identified by software as recoverable revenue.
Continue sampling completed work, including accounts the system handled without flagging a problem. Assign someone authority to suspend the tool when accuracy or controls deteriorate, and maintain a workable fallback process.
Expansion should follow demonstrated results from the pilot. Hospital leaders should be able to explain what improved, what it cost, and who remains accountable when the system makes a mistake.
Source links for editorial review. Checked November 3, 2026.
1. Chang W, Owusu-Mensah P, Everson J, Richwine C. Hospital Trends in the Use, Evaluation, and Governance of Predictive AI, 2023–2024. ASTP Data Brief No. 80. September 2025. Read the source
2. KFF. AI at Scale: Does It Deliver? The Business of Health with Chip Kahn. Interview with Michael Schlosser; published transcript. May 26, 2026. Read the source
3. Afshar M, et al. A Novel Playbook for Pragmatic Trial Operations to Monitor and Evaluate Ambient Artificial Intelligence in Clinical Practice. NEJM AI. doi:10.1056/aidbp2401267. August 28, 2025. Read the source
4. Pillai D, Artiga S, Ndugga N. The Growing Use of Artificial Intelligence in Health Care and Implications for Disparities. KFF. April 30, 2026. Read the source
This article was originally published on RACmonitor.
November 11, 2026
Carelon will pay more than $10 million across two settlements in New York over mental health networks and coverage denials.
This article was originally published on Fierce Healthcare.
November 9, 2026
HealthTap is rolling out a new program for Medicare Advantage plans that seeks to help members form a connection with a primary care doctor that carries forward.
This article was originally published on Fierce Healthcare.
Author: Juliet Ugarte Hopkins, MD, ACPA-C | November 9, 2026
No matter how skilled your physician advisors and utilization management team may be, your patient status efforts will not succeed unless you actively educate the medical staff.
Under the Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 412, Subpart A, § 412.3, an Inpatient order must be provided by a practitioner who has admitting privileges and is “knowledgeable about the patient’s hospital course, medical plan of care, and current condition.” If, based on the “patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event,” the practitioner anticipates that the patient will require hospital care spanning two midnights, Inpatient status is supported. Nowhere in this rule does it say that a utilization review nurse can review laboratory and imaging results, ordered and administered medications, and incomplete physician notes, and then recommend a specific status order for the admitting attending physician.
Yes, collaboration among the utilization review nurse, a physician advisor when appropriate, and the attending physician is often a key part of the process for assigning hospitalized patients to the correct status. Even before that collaboration occurs, however, the initial key to success is ensuring that the attending physician has a solid understanding of the Medicare Two-Midnight Rule and knows how to apply it.
Physicians did not attend medical school to learn the business of medicine. They went to learn how to care for patients; to diagnose, treat, and alleviate illness. However, the days when physicians could turn a blind eye to matters outside direct clinical care are long over. When the Centers for Medicare and Medicaid Services (CMS) put the Medicare Two-Midnight Rule into effect just over 13 years ago last week, it essentially mandated clinician education on the Rule. Yet, 13 years later, I continue to work with hospitals and health systems across the country that have failed to provide this training.
Set aside MCG and InterQual criteria: your physicians do not need to be versed in them, although your physician advisors should be. The intricacies of assigning status to commercial and Medicaid patients should remain with utilization review nurses; clinicians need only understand that utilization managers will routinely contact them when those patients require a status change. What I want the admitting and attending medical staff to know is the Two-Midnight Rule. According to CMS, this education is not optional, and hospitals should recognize it as a compliance issue.
The foundational elements of the Two-Midnight Rule that should be taught include the following:
Physicians and advanced practice providers (APPs) who should receive this education include anyone who could be responsible for a patient’s hospitalization. The initial and most concentrated educational effort should begin with the following groups:
The best method for disseminating this education depends largely on the size of the hospital, the structure and scheduling of departmental meetings, and the number of physician advisors available to provide the training. Smaller and mid-sized hospitals may find that offering several in-person or virtual presentations allows clinicians to choose the dates and times that work best with their schedules. Larger health systems may benefit from creating recorded modules that medical staff can watch on demand. In every setting, after a comprehensive effort to educate existing clinicians, the organization should establish a plan to ensure that the material is incorporated into the onboarding process for all new medical staff members going forward.
Not to overlook my pediatric colleagues, these concepts apply to children’s hospitals and to hospitals with large pediatric and neonatal populations as well. The Medicare Two-Midnight Rule will not be the focus in those settings, but the applicable state Medicaid rules governing patient status certainly should be. Comprehensive, detailed clinician documentation is important across all patient populations to support appropriate reimbursement and avoid medical-necessity denials, but I believe it is even more critical for pediatric patients. Children may arrive at the hospital on death’s door and then, almost miraculously, recover quickly after receiving excellent medical care, allowing discharge within a day or two. Because of these common “rapid recoveries,” children’s hospital claims are notoriously denied for Inpatient status.
Neonatal Intensive Care Unit (NICU) statusing should not be overlooked, either. Because the appropriate level of care must be established day by day based on the baby’s condition and treatment needs, consistent and precise categorization is essential. If you are a physician advisor at a hospital with a NICU and are not involved with this patient population, now is the time to begin asking questions. In my travels across the country, this is yet another service gap I frequently encounter in physician advisory services and utilization review. Claims involving these tiny patients can leave a serious dent in a hospital’s finances: NICU care is extremely expensive, and the corresponding denials are equally costly. Just as adult intensivists should understand the connection between their documentation and hospital reimbursement, neonatologists should understand that connection as well. If particular documentation elements support a higher level of statusing but are often missing, those points should also become a focused area of education for these physicians and providers.
This article was originally published on RACmonitor.
November 6, 2026
Humana beat the Street for both earnings and revenue in the third quarter. The company reported $162 million in profit and $41.2 billion in revenue for Q3, both of which surpassed analysts’ predictions, per Zacks Investment Research.
This article was originally published on Fierce Healthcare.