Becker's Hospital Review

8 CFO / FINANCE through July 21 on strategies to strengthen compliance, enforcement and data accuracy. 8. On April 4, CMS published its final rule for Medicare Advantage and Part D in 2026. While the final rule solidifies several changes — including measures to streamline prior authorization, tighten oversight of supplemental benefits and codify provisions from the Inflation Reduction Act — CMS stopped short of addressing two of the most closely watched issues: expanding coverage for GLP- 1s under Medicare and Medicaid, and regulating the use of AI in prior authorization. ose decisions have been deferred to future rulemaking. 9. CMS plans to increase payments to MA plans by more than $25 billion in 2026. MA plans can expect a payment increase of 5.03% in 2026, more than double what the Biden administration proposed. e agency will continue the final year of the phase-in of risk-adjustment changes, shiing MA's diagnosing coding from ICD-9 to ICD-10 and remove certain codes from the hierarchical condition categories model. 10. CMS plans to audit every MA plan annually as part of what it calls an "aggressive" effort to strengthen oversight and address potential overpayments. e agency currently audits about 60 plans each year but intends to expand that to all 500-plus MA plans moving forward. In addition to the expanded audit scope, CMS said it will intensify efforts to recover uncollected overpayments from previous audits and complete outstanding reviews from 2018 through 2024. e last major recovery effort targeted plan year 2007. To support this initiative, CMS plans to grow its team of medical coders from 40 to approximately 2,000 by Sept. 1 and will deploy "enhanced technology" to streamline the review of medical records. "While the administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients," Dr. Oz said. 11. On April 10, CMS said it is halting federal matching funds for state expenditures on designated state health programs (DSHP) and designated state investment programs (DSIP) "to preserve the core mission of the Medicaid program." 12. In early April, CMS proposed a series of payment updates across multiple care settings for fiscal 2026, including a 2.4% payment increase for inpatient hospitals, equating to a $4 billion funding increase. n The greatest financial threat to hospitals, per revenue cycle leaders By Andrew Cass N early half of hospital revenue cycle leaders view payer denials as the single greatest threat to their organization's financial performance, according to a report from RCM company Knowtion Health, featuring joint research with Healthcare Financial Management Association. The report is based on a nationwide survey of 147 revenue cycle leaders, according to a June 26 Knowtion news release. Four things to know: 1. 48% of leaders surveyed said denial volume now surpasses all other revenue threats, including declining reimbursement, labor shortages and analytics gaps. 2. 47% said that appeals now take more than twice as long as they did three years ago. 3. Half of the leaders surveyed said they have seen a significant increase in payer requests for information over the past year. 4. 38% cited difficulty prioritizing denials based on revenue impact as their top barrier to recovery. n The greatest barriers to improving appeals performance By Andrew Cass P ayer communication difficulties are the greatest barrier to improving appeals performance, according to a report from RCM company Knowtion Health, featuring joint research with the Healthcare Financial Management Association. e report is based on a nationwide survey of 147 revenue cycle leaders, according to a June 26 Knowtion news release. Here are the top barriers to improving appeals performance, according to the report. Revenue cycle leaders were asked to select up to three responses. 1. Payer communication difficulties: 75% 2. Denial volume is too high to prioritize appeals optimally: 56% 3. Insufficient appeal tracking and analytics: 44% 4. Responses are too cookie-cutter: 31% 5. Access to clinicians: 28% 6. Access to attorneys: 11% 7. Access to billing specialists: 10% n

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