Creating financial sustainability and managing time-consuming and frustrating payment policies are continuing challenges, with pressure mounting from both governmental and commercial payors. Tracking these ever-evolving trends should be a core task of your revenue cycle management team.
Whether it’s downcoding—when a payor assigns a lower-paying Current Procedural Terminology code for a medical service or procedure than what the healthcare provider originally submitted—or delayed or denied payments caused by overly restrictive prior authorizations, you need to remain educated about these trends to minimize any financial hits to your health system.
Data integrity is another critical key to your department’s survival; it cannot be a casualty of downsizing. So, it’s time to step up and contribute to the operational resilience, revenue cycle innovation and targeted advocacy that your leaders should be championing.
This column examines eight important issues or programs that are being considered. Familiarize yourself and follow them to prepare for how they might affect the healthcare system and your department.
Proposed Medicaid cuts. These cuts threaten patient access to care, particularly for safety-net hospitals and those eligible for the federal discount 340B Drug Pricing Program. Many proposals in flux aim at patient eligibility, rebate models and contract pharmacies, and may conflict with the Inflation Reduction Act.
“Most Favored Nation” pricing policy. This policy aims to align pharmaceutical prices in the United States with the lowest global rates. The current administration also plans to set up a system for patients to buy drugs directly from pharma companies at lower prices and demand that those companies begin drug price negotiations, starting this summer, according to media reports.
Action step: As with other mandates or rules that will affect Medicare Part D pricing, have you begun conversations with your hospital leaders about the implications for cost of goods, revenue erosion and other potential changes?
Medicare Drug Price Negotiation Program (MDPNP). The Centers for Medicare & Medicaid Services (CMS) has published a new draft guidance on the MDPNP. Under the program, the secretary of the Department of Health and Human Services works directly with pharmaceutical manufacturers to negotiate the prices that Medicare will pay for medications. The MDPNP is part of the Inflation Reduction Act, signed into law by President Joe Biden in 2022, which for the first time authorized the federal government to negotiate the prices that Medicare pays for selected prescription medications.
There are several moving parts to the MDPNP that you need to keep an eye on. One is the requirement that Medicare Part D beneficiaries pay no more than the negotiated maximum fair price (MFP) for a selected drug when dispensed. Since it’s possible that pharmacies may pay more than the MFP to acquire the drug, there is a tool known as the Medicare Transaction Facilitator (MTF) that connects pharmacies with manufacturers so they may receive refund payments from the manufacturers for eligible drugs. Each pharmacy must enroll in MTF to participate in the refunding process. The program takes effect Jan. 1, 2026.
Action step: If your ambulatory care pharmacy chooses to participate in this program to lower costs for your patients, ensure that you are taking advantage of the ways that the MTF program can mitigate any resulting losses. For more information on the MDPNP, see a CMS overview.
Interoperability Rule. The Office of the National Coordinator for Health Information Technology (ONC) interoperability rule would attempt to improve interoperability between payors, public health organizations and providers by establishing voluntary certifications for health IT software tools. One of the main aims of the rule is to standardize electronic prior authorization technology to reduce documentation requirements and decrease administrative costs.
Action step: Watch for publication of the rule; facilities can offer input during a 60-day public comment period. More information on the rule, which is part of the 21st Century Cures Act, can be found in the Federal Register.
Hospital price caps. Over the past year, several states introduced bills that limit hospital care prices to curb cost growth. Early price cap adopters are Rhode Island and Oregon. Other states want to crack down on hospital prices because cost growth benchmarks, price transparency and other policies have yet to affect healthcare spending.
Action step: Keep an eye on whether price caps will lead to service cuts.
Price transparency. CMS updated its hospital price transparency (HPT) guidance May 22, requiring hospitals to post the actual prices of items and services, not estimates. The update was a result of a presidential executive order issued Feb. 25 that aimed to boost healthcare price transparency. CMS has fined 10 hospitals in 2025 for noncompliance. Additionally, CMS issued a Request for Information seeking public input on how to improve HPT compliance and enforcement processes to ensure that hospital pricing data in the machine-readable file (MRF) are accurate and complete. The HPT guidance relates to the president’s executive order 14221 to ensure compliance with the transparent reporting of complete, accurate and meaningful HPT data.
Action step: Are you maintaining your charge description master and pharmacy drug master files in a timely fashion to show actual products and prices? The HPT guidance indicates that hospitals must encode a standard-charge dollar amount in the MRF if it can be calculated, and hospitals should discontinue coding 999999999 in the estimated allowed amount data element. Get educated about the key stipulations of these important policies by reading a May 22, 2025 announcement and a White House fact sheet.
“Dual-eligible” Medicare/Medicaid beneficiaries. An aging population and other demographic shifts have led to a dramatic growth in this group of patients who are not only poorer than average, but much more likely to have chronic illnesses and substantial healthcare needs.
Action step: How do you coordinate prescription coverage and offerings of ambulatory clinical services?
Advanced therapeutics. The list of items that might fall into this category is only just beginning, ranging from specialty pharmacy medications with novel infusions and routes of administration to chimeric antigen receptor (CAR) T-cell therapy, CRISPR, and cell and gene therapies. The use of these treatments requires a completely different approach, with some health systems drafting committees to coordinate care. These committees typically include people with expertise in medication-use processes and clinical monitoring, as well as individuals who can help navigate the complexities of prior authorizations, reimbursement and patient assistance programs. Getting these components right is critical, given that some of these therapies can cost upward of $1 million for a full course of treatment.
Action step: Make sure your health system is proactively preparing for advanced therapeutics. The financial considerations are astronomical and must be considered in policy development. Safety for patients and all practitioners is paramount!
This article is from the August 2025 print issue.