October 9, 2026
Federal regulators released the hotly anticipated star ratings for the 2027 Medicare Advantage plan year, and winners and losers emerged in the data.
This article was originally published on Fierce Healthcare.
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October 9, 2026
Federal regulators released the hotly anticipated star ratings for the 2027 Medicare Advantage plan year, and winners and losers emerged in the data.
This article was originally published on Fierce Healthcare.
October 8, 2026
The Trump administration has released the 2027 Medicare Advantage star ratings, with many enrollees in plans that earned at least four stars.
This article was originally published on Fierce Healthcare.
October 8, 2026
A survey of 52 experts spanning researchers, the Medicare Advantage industry, patient advocates and policymakers wasn’t able to identify a single policy proposal that would be received wholeheartedly by all three groups.
This article was originally published on Fierce Healthcare.
Author: Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI | October 7, 2026
Well, we are officially in fiscal year (FY) 2027, and the start of all the provisions of the 2027 Inpatient Prospective Payment System (IPPS) Final Rule. And that means all the hard work you did to reduce length of stay and increase your hospital’s case mix index (CMI) over the last year is out the window. Why is that?
Because Oct. 1 is when the Centers for Medicare & Medicaid Services (CMS) resets all the Diagnosis-Related Group (DRG) weights and the geometric mean length of stay (GMLOS). And because everyone is always trying to shorten length of stay and reduce costs, the data that CMS uses to reset the values each year suggests that patients are discharged sooner and cost less. Sometimes you just can’t win.
We are also approaching open enrollment season, when beneficiaries can switch their Medicare plans. They can go from traditional Medicare to Medicare Advantage (MA), switch to a different MA plan, or give up their MA plan and go back to traditional Medicare. But note that if they switch back to Medicare, they may not be able to obtain a supplement.
Because it is complex, many Medicare beneficiaries use insurance brokers to help pick a plan. And the Center for Medicare Advocacy issued a warning a couple of weeks ago that there are increasing reports of these brokers aggressively cross-selling other insurance products. The Center advises beneficiaries to ask questions, and urges them not to fall for high-pressure sales tactics. Help your family and friends who face these decisions understand their options.
The Center also issued a report on increasing number of cases of Medicare beneficiaries with a MA plan who reside in nursing facilities that disenroll them from the MA plan without their knowledge or consent. CMS first put out a notice about this in 2015, so it is not new, but it sure is unethical.
While there is no clear explanation given, one has to think that the facilities want to get patients back on Medicare Parts A and B so they can provide covered care like therapy services without having to go through the pain of getting authorization from the MA plan and having to submit notes every few days to get the authorization extended.
The Center for Medicare Advocacy is a great organization. If you are not subscribed to their free weekly newsletter, do it now.
Next, I have talked about site neutrality before. Payers want it so they don’t have to pay a hospital more for a surgery that could have been done at a lower cost to them at a surgery center or physician office. So far there is only talk in Washington. But one payer, Elevance Health, has figured out a workaround to reduce their expenditures.
They are going to start requiring that claims for services at hospital-owned facilities include the address where the service was actually provided, rather than just billing with the hospital’s information. That will allow them to adjust payment for services that were performed off-campus to the same rate they would pay an independent facility not affiliated with a hospital or health system. Just as Aetna did with their severity index plan, the payers are figuring every way they can to reduce their costs and increase their profits.
Finally, Oct. 1 marked the loss of Medicaid coverage for hundreds of thousands of immigrants who are lawfully present in the country, but do not have permanent resident status. This adds to the estimated 760,000 people who were disenrolled from their Marketplace plan by CMS a couple of weeks ago. Many of these people will end up in our hospitals needing medical care, and once again it will fall upon many of you to develop a safe and effective plan for them.
There is a bit of irony about this in that Oct. 1 also marks the start of Case Management Month, when we honor the vital contributions of case and care managers across the healthcare continuum. And I thank all of you for everything you do every day for our patients.
This article was originally published on RACmonitor.
October 6, 2026
Last month, SCAN Health Plan revealed that it would team up with Walmart to launch co-branded Medicare Advantage plans in two states. Now, the partners are offering a deeper look at how those benefits have taken shape, and why they saw potential in coming together.
This article was originally published on Fierce Healthcare.
October 5, 2026
Texas Attorney General Ken Paxton announced on Monday that he would launch an investigation into industry giant UnitedHealth Group for “engaging in deceptive and unlawful practices” that may have denied care to Texans.
This article was originally published on Fierce Healthcare.
October 5, 2026
The settlement resolves allegations from 2017 to 2021 that the company submitted “inaccurate and untruthful” diagnoses data to CMS.
This article was originally published on Fierce Healthcare.
Author: Knicole C. Emanuel Esq. | October 1, 2026
Every provider that bills Medicare has felt the sting of a denied claim. Some denials are one-off mistakes: a transposed digit, a missed modifier. But others show up with frustrating regularity, draining revenue, consuming staff hours, and delaying payment for care that was unquestionably needed and delivered. Understanding the most common denial patterns is the first step toward preventing them.
CO-50: Medical Necessity — The Big One
No denial code haunts providers quite like CO-50: “these are non-covered services because this is not deemed a ‘medical necessity’ by the payer.” This denial means the Medicare Administrative Contractor (MAC) has determined that the documentation submitted does not support the clinical need for the service billed. It does not necessarily mean that the care was inappropriate; it means the record, as presented, did not make the case.
The fix starts before the claim is ever submitted. Ensure that clinical documentation clearly connects the diagnosis to the service, references applicable Local Coverage Determinations (LCDs), if necessary, and explains why alternative treatments were insufficient, if necessary. When CO-50 denials occur, providers should pursue a redetermination under 42 CFR § 405.904, supported by strengthened documentation.
CO-4: The Procedure Code Does Not Match the Diagnosis
CO-4 flags a mismatch between the procedure code and the diagnosis code on the claim. This is often a coding error, rather than a clinical one: the service was appropriate, but the claim told a contradictory story. Common culprits include outdated ICD-10 mappings, unspecified diagnosis codes when a more specific code was available, and copy-forward errors in the electronic health record (EHR).
Prevention requires routine audits of code pairing logic and close collaboration between clinical and billing teams. A coder who understands the clinical rationale – and a clinician who understands coding requirements – can catch these mismatches before submission.
CO-29: The Filing Deadline Has Passed
CO-29 – “the time limit for filing has expired” – is one of the most preventable and least forgivable denials. Medicare generally requires claims to be filed within one calendar year from the date of service. Miss that window, and you have no appeal right; the revenue is simply gone.
This denial typically results from workflow bottlenecks: delayed charge capture, unresolved claim edits sitting in a work queue, or rebilling after a prior rejection without tracking the original timely filing date. Automated deadline alerts and aging reports are essential safeguards.
CO-16 and CO-18: Missing or Invalid Information
CO-16 (“claim/service lacks information or has submission/billing error(s)”) and CO-18 (“exact duplicate claim/service”) are high-volume, low-complexity denials that point to front-end process failures. CO-16 often traces back to missing referring provider information, incomplete patient demographics, or absent prior authorization numbers. CO-18 results from inadvertent resubmission of a claim that was already adjudicated.
Both are preventable with clean claim scrubbing software and staff training on resubmission protocols. The goal is to catch these before the claim leaves your system.
PR-96: Non-Covered Charges Under the Patient’s Plan
PR-96 denials indicate that the billed service is not covered under the patient’s specific Medicare benefit category. This frequently arises with screening services, certain preventive procedures, or services subject to frequency limitations. Providers should verify coverage eligibility and benefit-specific restrictions at the point of scheduling, not after the claim is returned.
The Bigger Picture
The common thread across these denials is that most are preventable at the point of documentation or submission, not at the point of care. Providers rarely deliver unnecessary services, but they routinely fail to document the necessity in the language Medicare requires, code the claim in a way that tells a coherent clinical story, or submit it within the rules that govern the process.
Building a denial management program that tracks patterns, identifies root causes, and feeds corrections back into the front end is not optional; it is the difference between a revenue cycle that functions and one that hemorrhages.
Every denied claim is a lesson. The question is whether your organization is learning from them.
This article was originally published on RACmonitor.
Author: Matthew Albright | October 1, 2026
The House has gone home until after midterms, and the Senate has one foot out the door. In the meantime, let’s take a spin around the Beltway and see what’s percolating with the administration’s healthcare policies.
We’ll start with the Wasteful and Inappropriate Service Reduction (WISeR) model: Medicare’s artificial intelligence- (AI)-driven prior authorization pilot, which is coming up on its one-year anniversary.
We’ve seen reporting over the past year on the WISeR model – most of it from the point of view of the provider, none of it good (see Fierce Healthcare, Center for Medicare Advocacy, WaPo) – but last week was the first time we were able to read internal Centers for Medicare & Medicaid Services (CMS) documents on WISeR’s implementation in the first quarter of 2026.
The internal documents were published by the nonprofit group the Electronic Frontier Foundation (EFF). EFF was given the materials as part of a Freedom of Information Act (FOIA) lawsuit, and according to EFF, the documents confirm what some providers had been saying throughout 2026: instead of speeding up prior authorizations, the technology faced widespread operational problems during its launch and appeared to cause “lengthy treatment delays” in patient care. Newsweek, STAT, and Fierce Healthcare all covered EFF’s findings.
Also last week, we heard more news on the 80-hour-a-month Medicaid work requirements, which take effect this January: recall that, in its June 2026 rule implementing the work requirement, CMS said that only beneficiaries who were too medically frail to work could be exempted from the requirement. There was an immediate reaction from providers on how CMS defined “medically frail,” which opponents said would result in administrative difficulties for beneficiaries, providers, and the states.
Last week, CMS provided guidance on the 80-hour requirement by showing an example of how states might identify beneficiaries as medically frail through a tiered system.
At about the same time CMS released the guidance, a lawsuit on the 80-hour requirement was filed by five Medicaid beneficiaries and a group of provider organizations.
The suit argues that the medically frail definition is too narrow, and that the requirement would force providers to make determinations that fall outside the scope of the usual patient-provider relationship. Earlier this summer, 25 states also filed suit against the rule, saying it dramatically narrowed the exclusions established by Congress in the One Big Beautiful Bill Act (OBBBA).
In contrast, a handful of GOP-controlled states are imposing tougher requirements around the medically frail exception than the June rule imposed. In the rule, CMS allows beneficiaries to self-attest to the medically frailty exception in the first year, with supporting documentation required in 2028. However, at least six states are requiring beneficiaries to provide documentation demonstrating their medical frailty in 2027; that is, the first year of the work requirement.
Finally, last week, Zelis’s Cate Brantley reported on some of the tensions in healthcare AI policy, particularly between the states and the federal government.
Cate noted how the administration is broadly enthusiastic about AI, with the U.S. Department of Health and Human Services (HHS) actively pursuing reimbursement models built around it, including the WISeR model and the ACCESS model Cate reported on last week.
Last week, healthcare AI policy seemed to come head-to-head with an even more contentious healthcare policy issue: affordability.
CMS Administrator Dr. Mehmet Oz made news when he said that AI is likely to make healthcare more expensive in the short term. At a conference last week, Dr. Oz talked about how AI is “turbocharging the ability of the current billing systems to work more effectively.” But, in so doing, in the near term, “AI is going to be inflationary,” he said.
The Administrator’s comments came out at about the same time the Blue Cross Blue Shield Association released an analysis alleging that AI coding tools have likely added around $1 billion in healthcare costs between 2023 and 2025.
We’ve finished circling the Beltway for today, and talking healthcare policy.
Even when Congress leaves town, there’s still a lot of traffic on both.
This article was originally published on RACmonitor.
September 30, 2026
With Medicare’s annual enrollment period on the horizon, major insurers are offering a look at their plans for the coming year and new federal data offers a broader look at the current landscape.
This article was originally published on Fierce Healthcare.