On April 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a Final Rule (CMS-4201-F) regarding the Medicare Advantage (MA) and Part D programs. The Final Rule includes changes related to various aspects of...more
4/10/2023
/ Centers for Medicare & Medicaid Services (CMS) ,
Continuity of Care ,
Department of Health and Human Services (HHS) ,
Final Rules ,
Health Care Providers ,
Medical Necessity ,
Medicare Advantage ,
Medicare Part D ,
OIG ,
Regulatory Agenda ,
Regulatory Requirements ,
Two-Midnight Rule
UnitedHealthcare ("United"), the nation’s largest health insurer, is using a dual strategy to put downward pressure on provider reimbursement rates: (1) strategic contract terminations, combined with (2) heavy investment in...more
On March 13, 2020, President Trump declared the coronavirus pandemic a national emergency, invoking powers under the National Emergency Act and the Stafford Act. The President’s declaration, coupled with Secretary Azar’s...more
The move by some employer plans to a “reference-based” pricing model has created a need for healthcare providers to develop a strategy to confront payment challenges that these plans create. A prevalent model of...more
12/13/2019
/ Affordable Care Act ,
Department of Labor (DOL) ,
Employer Group Health Plans ,
Health Care Providers ,
Health Insurance ,
Out-of-Pocket Expenses ,
Pricing ,
Public Health Service Act ,
Regulatory Standards ,
TPAs ,
Uniform Commercial Code (UCC)
Health Plans’ Use of Policies and Guidelines to Reduce Coverage and Reimbursement -
A technique we have seen payers use more commonly in recent months than in the past is to unilaterally implement policies or “clinical...more