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Hospitals have a rational interest in standardizing prices across facilities.  This interest has only intensified with the introduction of Price Transparency requirements. The goal of standard pricing must be considered simultaneously with other goals such as price stability and changes in gross and net revenue. There are several complexities in this analysis that must be…

Payors and Providers wait for the release of the poverty guidelines each year to update patient financial assistance and eligibility information within their forms and systems. The 2023 Poverty Guidelines are effective January 16, 2023, and are now posted HERE. Poverty guidelines are issued each year in the Federal Register by the Department of Health and Human Services…

Starting with the January 2023 payment month, health plans will see the impact of dual status on their End-Stage Renal Disease (ESRD) members change from prior years. In 2023, CMS implements the changes to the ESRD payment models that were announced in the 2023 advance notice. The revised ESRD payment model is calibrated on more…

CLICK TO VIEW INTERACTIVE VISUALIZATION Once again, the U.S. Department of Health and Human Services (HHS) reported that the risk adjustment program operated smoothly for the 2021 benefit year. For the seventh year, the risk adjustment program is working as intended by more evenly spreading the financial risk carried by issuers that enrolled higher-risk individuals…

The U.S. Department of Health and Human Services (HHS) first declared a Public Health Emergency (PHE) in January 2020. Section 6008 of the Families First Coronavirus Response Act (FFCRA) as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act provides states with a temporary 6.2 percentage point increase in their federal medical assistance…

To Emergency and Beyond. From Pandemic to Endemic. Sounds like science fiction, but it is our reality and our future as we attempt to navigate through and beyond the COVID-19 virus our world has been plagued with for more than two years.   Record high Medicaid and CHIP enrollment During these two-plus years, enrollment in…

A key objective for an integrated health system is to keep provider referrals within the system. Many of the financial, patient outcome, and quality assumptions about a health system depend upon keeping the system, well, “integrated.” Most health systems in the U.S. do a good job putting together the right mix of clinical capabilities, medical…

Promoting Health Equity and Population Health Through Advancing the Use of Social Determinants of Health Data In the recently released  CY 2023 Medicare Advantage (MA) and Part D Proposed Rule (CMS-4192-P) CMS for the first time provides very specific guidance related to social determinants of health (SDoH). As a refresher, SDoH are the non-medical factors…

Payors and Providers wait for the release of the poverty guidelines each year to update patient financial assistance and eligibility information within their forms and systems. The 2022 Poverty Guidelines went into effect on January 12, 2022, and are now posted at https://aspe.hhs.gov/poverty-guidelines. Poverty guidelines are issued each year in the Federal Register by the Department of Health…