A team of researchers at Brown University, writing in the December issue of Health Affairs, is arguing that state employee health plans could institute payment caps that would save a great deal of money while not harming hospitals. Often the largest purchaser of commercial health insurance in their state, state employee health plans possess a unique opportunity to implement cost...

A group of legislators is calling on the Department of Justice to dig into whether pharmacy benefit managers played a role in the opioid epidemic. The representatives point to recent reports that suggest the three largest PBMs worked together to funnel patients to OxyContin prescriptions. "Recent reports, including confidential files and information from CVS Caremark,...

Ever since the COVID-19 public health emergency (PHE) was declared in 2020, telehealth billing rules have changed repeatedly, making it difficult to keep up. While many telehealth flexibilities are still in place, some will be going away effective January 1, 2025. That’s the word from the2025 Medicare Physician Fee Schedule Final Rule, which CMS released on November 1....

Hospital-at-home and telehealth reimbursement from CMS will expire at the end of 2024 without congressional action. Here are five things to know about what the CMS and Congress need to do to extend reimbursement for these programs.

The Centers for Medicare and Medicaid Services (CMS) is moving forward with a 2.9% cut to physician payments in 2025 despite protest from major industry groups. CMS announced Friday it finalized the calendar year 2025Medicare Physician Fee Schedule rulethat sets payment rates for next year and also outlines new policies focused on primary care, preserved telehealth...

Medicare Advantage (MA) insurers, namely industry titans UnitedHealth Group and Humana, could be using health risk assessments and chart reviews to inflate payments from Medicare through upcoding, according to a federal watchdog report. An estimated $7.5 billion in risk-adjusted payments was pocketed by MA insurers when diagnoses were only found on chart...

Humana, one of the country’s largest Medicare Advantage organizations, is suing the Centers for Medicare & Medicaid Services over its 2025 star ratings results. In a lawsuit with nonprofit trade association Americans for Beneficiary Choice, the insurer said the federal government's “arbitrary” actions violates the Administrative Procedure Act. “The data and calculations underlying the annual...