On July 15, 2025, CMS issued a proposed rule that proposes updates to Medicare payment policies and rates for hospital outpatient and Ambulatory Surgical Center services under the Hospital Outpatient Prospective Payment System and ASC Payment System Proposed Rule for calendar year 2026.
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By David Van Houtte – With a recent increase in rules and regulations from CMS, health plans are feeling the pressure of more scrutiny, and the fear of penalties looms. For example, the No Surprises Act, passed in 2022, has already resulted in healthcare facilities, payors, and providers paying more than $11 million in penalties.
By Kathryn Eshelman MD MPH – Unlike Medicare Advantage, risk adjustment in Medicaid is a zero-sum game. Medicaid is managed at the state level with fixed budgets, and the slice of the pie your health plan receives depends on the effectiveness of its risk adjustment program.
By Chelsea Richwine – In 2024, more patients than ever before accessed their medical records online through web browsers and apps to manage their health – here’s why that matters.
The calendar year 2026 Medicare Physician Fee Schedule proposed rule would advance primary care management through new quality measures, reduce waste and unnecessary use of skin substitutes, and introduce a new payment model focused on improving care for chronic disease management.
By Steven Posnack – As we roll into the second half of 2025, we wanted to state our TEFCA™ priorities and plans for the remainder of the year.
By Brian D. Handspicker – This post builds upon a recent blog by Lisa Nelson, Fractional Chief Technical Officer, “FHIR Over Direct: Accelerating the Pace toward Trusted, Scalable Interoperability,” by exploring how the same approach of FHIR Over Direct can be applied to socialcare — a critical but often underrepresented component of health and well-being.
By Arun Hampapur PhD – The U.S. healthcare industry is once again in the spotlight—this time, with the scrutiny on UnitedHealth. The Department of Justice has launched a civil fraud investigation into UnitedHealth Group, which highlights the ethical challenges and complexities around risk adjustment in Medicare Advantage.
As of July 1, 2025, the 2026 Self-Nomination period for Qualified Clinical Data Registries (QCDRs) and Qualified Registries is now open. QCDRs and Qualified Registries are Centers for Medicare & Medicaid Services -approved intermediaries that collect clinical data on behalf of clinicians for data submission.