CMS has fined two hospitals in September for alleged violations of its price transparency rule. This marks the third month in a row that the agency has issued fines against hospitals for price transparency noncompliance, following a yearslong period of light enforcement.

Only actual hospital prices, displayed as dollars and cents, not estimates, formulas, or algorithms, protect patients from outrageous bills and hold hospitals accountable for overcharges, errors, and fraud. Accepting CMS’ or other substitutes instead of actual prices undermines broader efforts to make hospital price transparency a reality for American patients and healthcare consumers.

CMS released a proposed rule to establish staffing standards among the nation’s nursing homes. Reactions have been mixed — but mainly negative. Long-term care facilities say that they can neither find nor afford more workers. On the other hand, some lawmakers argue the proposed rule doesn’t do enough to protect care quality for patients. As for labor unions, they seem generally happy with the rule.

Some states may not be following federal requirements for the Medicaid renewal process, resulting in many individuals being wrongly removed from coverage, CMS said. Children may especially be affected.

For the sixth year in a row, the Medicare Shared Savings Program created overall savings, CMS announced. When compared to clinician groups of a similar size not participating in the program, participating ACOs performed better on quality measures, including measures for diabetes, breast cancer and colorectal cancer screenings, tobacco screenings and depression screenings.

The role of the family caregiver is considered part of the cycle of life. But it can be time consuming and stressful, especially if caregivers have to balance their role with a job, raising children, and other aspects of family life. The topic will be one of many discussed at the HLTH event in Las Vegas from October 8-11.

CMS recently announced that it will change the administrative fee that providers and insurers must pay when initiating a reimbursement dispute under the No Surprises Act — the agency is lowering the fee from $350 to $50. This move came a week after the Texas Medical Association won a court case challenging HHS over its 600% price hike on the fee.

The average total monthly premium for Medicare Part D coverage is expected to be $55.50 in 2024, down from $56.49 in 2023, according to CMS.

About 36% of U.S. hospitals are in compliance with CMS’ price transparency rule, up from 24.5% in February, according to a new report. This progress will remain slow unless CMS can do a better job of effectively enforcing its rule, the report declared.

KFF found that the 10 top-selling Part D drugs represented $47.7 billion of the $215.7 billion total gross Medicare Part D drug spending in 2021. Eliquis, a blood thinner by Bristol Myers Squibb, accounted for the most spending out of these 10 drugs at $12.6 billion. 

CMS recently revealed its proposals to raise reimbursement rates for hospital outpatient departments and cut payments for physicians. Next year, the agency is planning to decrease physicians’ pay by 1.25% and increase outpatient payment rates by 2.8%. Provider groups are unhappy with the news — AMA President Dr. Jesse Ehrenfeld said the new physician fee schedule will be “almost biblical in its impact.”

CMS recently proposed a $9 billion lump sum payment to remedy illegal payment cuts for 340B drugs from 2018 to 2022. In general, hospital groups have reacted positively to the fact that 340B providers will receive lump sum payments but have expressed concern about CMS’ methods for maintaining budget neutrality with this plan.

The Making Care Primary Model will be tested by the Center for Medicare and Medicaid Innovation from July 1, 2024, to December 31, 2034, in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina and Washington.

Medicare could have saved $128 million if the Centers for Medicare and Medicaid Services had the correct controls in place to avoid duplicate payments with the Veterans Health Administration, an audit by the Office of Inspector General found.

CMS recently fined two hospitals for alleged violations of its price transparency rule. These fines are only the third and fourth penalties issued by the agency since the rule took effect on January 1, 2021. These fines may become more common — CMS also announced that it is updating its enforcement process for the rule.

A shift from fee-for-service payment models to value-based models is not an effective way to address the severe financial pressures that safety net hospitals are facing, experts argued at the HIMSS conference in Chicago. One called for a paradigmatic shift “away from cost savings and toward understanding where investments are needed.”

A similar bill appeared last year but did not progress. Given the potential costs of reimbursing prescription digital therapeutics, Congress could be skeptical. Still, with growing attention on mental health, advocates are optimistic.

During a panel at the AHIP Medicare, Medicaid, Duals and Commercial Markets Forum, three executives were asked what gives them comfort about the return to Medicaid redeterminations, as well as what worries them. One CMS official said she’s pleased that states are ramping up communication efforts for Medicaid enrollees, but is concerned about the “insurmountable task” ahead.

Conducted by researchers at the University of Colorado medical school, the new report is the latest to gauge the extent of a costly problem that federal regulators are working to solve: Information about doctors varies from provider directory to provider directory.

At the AHIP Medicare, Medicaid, Duals and Commercial Markets Forum held last week, two healthcare leaders from the Centers for Medicare and Medicaid Services (CMS) and CVS Health stressed that reducing maternal health disparities is a top priority, with several strategies at play. For CMS, the focus is on encouraging states to extend Medicaid postpartum coverage, while CVS Health is working to leverage doulas in their care delivery.

CMS recently established a unique code for AppliedVR’s flagship product, marking the first time a digital therapeutic or immersive therapeutic has ever been placed in an existing benefit category. The eight-week program is a physician-prescribed solution that allows patients to manage their chronic lower back pain without opioids from the comfort of their own home.

CMS should honor its commitment to Medicare beneficiaries, especially those who began home respiratory therapy under the PHE, without requiring them to “restart” the documentation process. Requiring requalification would also be a nightmare for physicians who are already overwhelmed with patient demands.

CMS put out a request for information in October about a CMS-led national provider directory that would allow patients to find and compare providers based on preferences like language and location. Alexandra Mugge, director and deputy chief health informatics officer of the Health Informatics and Interoperability Group at CMS, said there is stakeholder support for the national directory — if it’s executed correctly.

Companies who raised drug prices higher than the rate of inflation must rebate the difference to Medicare, according to a provision of the Inflation Reduction Act. The highest-profile product on the list might be AbbVie’s blockbuster immunology drug Humira.

During an interview at the AHIP Medicare, Medicaid, Duals and Commercial Markets Forum held Tuesday in Washington, D.C., CMS Administrator Chiquita Brooks-LaSure discussed CMS’ key focus areas for 2023. This includes the end of the public health emergency, health equity and prescription drug costs.

For the first time ever, CMS is preparing to negotiate prices for drugs paid for by Medicare. This has sparked a huge debate — will the creation of this taxpayer-funded drug negotiation infrastructure be a failed experiment, or will it become the standard for the future of drug pricing in this country? Jason Borschow, president and CEO of Abarca Health, says it’s the latter.

The U.S. Department of Health & Human Services announced three models Tuesday that will be tested by the CMS Innovation Center and aim to lower prescription drug costs. The models, which include access to $2 generic drugs, build on the Inflation Reduction Act of 2022.

The final rule calls for stricter audits on Medicare Advantage plans. AHIP president and CEO Matt Eyles referred to the rule as “unlawful and fatally flawed.”

Pearl Health — a technology company that helps independent physician practices participate in value-based care models — just raised $75 million in Series B financing. Pearl’s platform leverages data science to help primary care providers focus on patients who are driving expenses and need care the most.

This year’s ACA Marketplace enrollment represents a 13% increase, or 1.8 million people, from last year, according to CMS. There were more than 12.7 million returning consumers and more than 3.6 million new consumers.