Tag Archives: Healthcare

Congress Could Force Patients in Rural America To Make Dire Medical Care Choices

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Bankruptcy, Financial Distress, Financial Instability, Financial Stewardship, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid, Medicaid Cuts, Rural Health, Rural Hospital, Uncompensated Care, Underinsured, Uninsured • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/congress-could-force-patients-in?utm_source=post-email-title&publication_id=255152&post_id=166944373&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

New Medicaid funding rules proposed by Congress this week would halt efforts at the state level to better fund rural hospitals and deliver services to the most vulnerable populations in those areas. You can be certain that the administrators and staff of those hospitals, as well as leaders of the communities they serve, are watching closely to see if the cuts are enacted. 

Lawmakers at the federal level are trying to make deeper cuts to Medicaid spending in an effort to lower the amount of deficit spending that would be created by President Trump’s spending plan. Trump has dubbed the plan his “big beautiful bill.” 

Feds Would Strip Rural Hospitals of Lifeline Funds

Republican members of the Senate Finance Committee this week released their version of the bill that would drain funding for rural hospitals, which rely heavily on Medicaid funds to treat patients. It’s estimated that 25 to 40 percent of services provided by such hospitals are funded by Medicaid.

The federal government and states share the up-front medical costs for Medicaid patients. The federal government then reimburses states up to 50 percent of their Medicaid spending every year.

Many states fund their portion of the cost by taxing entities that provide those services to Medicaid patients.

The latest proposal in Congress would not only restrict how many patients could receive benefits, but it would also stop states from implementing those provider tax programs to help fund Medicaid services provided to residents.

At the federal level, the thinking is that if states keep taxing providers to fund Medicaid services, then the federal government will have to keep reimbursing states a portion of those costs. 

The downside to that is many experts, along with several Republicans in Congress, namely Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and Josh Hawley of Missouri, have predicted it will decimate rural hospitals.

West Virginia Republican Sen. Jim Justice went a step further, saying that the plan to limit states’ use of provider taxes will “really hurt a lot of folks.” Despite that statement, Justice said he is OK with the freeze.

State Lawmakers Sound the Alarm

There are 39 states with at least three or more provider taxes used to help fund Medicaid services. Alaska is the only state with no such tax.

Some states, such as Ohio, have set up a new rural hospital fund using provider taxes to help rural hospitals deliver Medicaid services to patients.

Ohio Governor Mike DeWine and the Republican-led state legislature set up a pilot program called the Rural Ohio Hospital Tax Pilot Program. The measure would allow counties to levy a tax on their local hospitals that would then be used to fund Medicaid services.

DeWine said the pilot program would help ease the financial stress rural hospitals face in Ohio. The plan contained in Ohio House Bill 96 has the blessing of the Ohio Hospital Association.

That state fund reportedly would be neutered by the federal proposal. Ohio has at least three different provider taxes.  

A group of Republican state lawmakers recently sent a letter to their federal counterparts pleading with them to remove the bill language because it would “torpedo” plans to keep rural hospitals functioning.

The American Hospital Association, a 130-year-old trade group of more than 5,000 hospitals and health care providers, this month released the impact on rural hospitals if this plan went into effect.

 More than $50 billion would be lost by 2034, and more than 1.8 million rural Americans would lose health benefits.

Kentucky residents would be impacted the most, with 143,000 losing benefits, followed by 135,000 Californians. More than 86,000 Ohioans would lose Medicaid coverage under the plan by 2034, making it the third most impacted state.

To blunt the effects of the cuts, Collins reportedly is proposing the establishment of a $100 billion relief fund that could provide financial support to affected providers, rural hospitals in particular. Whether that or a similar but smaller fund will wind up in the final draft of the legislation apparently will be decided this weekend. Meanwhile, the Senate parliamentarian has ruled against many of the provisions of the Senate version of the bill, including the Finance Committee’s provider tax framework, which puts the whole thing in flux.

Senate leaders say they plan a long series of votes on amendments of the bill on Sunday. The “vote-arama” likely will go on throughout Sunday night and into Monday. If the Senate does pass its version of the bill, it will have to go back to the House. Lawmakers are under a self-imposed deadline to get the legislation to Trump by the July 4 holiday.

Federal Medicaid cuts imperil rural hospitals and residents

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Bankruptcy, Deferred Healthcare, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid, Medicaid Cuts, Medicaid Eligibility, Medicaid Funding, Nursing Home, Rural Health, Rural Hospital • Tagged , , , , • Leave a comment

https://www.ruralhealth.us/blogs/2025/06/federal-medicaid-cuts-imperil-rural-hospitals-and-residents-new-report-finds

Medicaid serves as a vital source of health insurance coverage for Americans living in rural areas, including children, parents, seniors, individuals with disabilities, and pregnant women. Congressional lawmakers are currently considering more than $800 billion in cuts to the Medicaid program, which would reduce Medicaid funding and terminate coverage for vulnerable Americans.

The proposed changes would also result in a significant reduction in Medicaid reimbursement that could result in rural hospital closures.

The National Rural Health Association recently partnered with experts from Manatt Health to shed light on the potential impacts of those cuts on rural residents and the hospitals that care for them over the next decade.

The report, Estimated Impact on Medicaid Enrollment and Hospital Expenditures in Rural Communities, provides insight into the impact on rural America at a critical moment in the Congressional debate over the future of the reconciliation package.

NRHA held a press conference on June 24 that can be accessed with passcode MBTZf4$H. NRHA chief policy officer Carrie Cochran-McClain discussed the findings with Manatt Health partner and former deputy administrator at CMS Cindy Mann and the real world implications of the details of this report with three NRHA member hospital and health system leaders

Report findings provide insight into the impact on rural America at a critical moment in the Congressional debate over the future of the reconciliation package.

The report shows the significant impact from coverage losses that rural communities will face given:

  • Medicaid plays an outsized role in rural America, covering a larger share of children and adults in rural communities than in urban ones.
  • Nearly half of all children and one in five adults in small towns and rural areas rely on Medicaid or CHIP for their health insurance.
  • Medicaid covers nearly one-quarter of women of childbearing age and finances half of all births in these communities.

According to Manatt’s estimates, rural hospitals will lose 21 cents out of every dollar they receive in Medicaid funding due to the One Big Beautiful Bill Act. Total cuts in Medicaid reimbursement for rural hospitals—including both federal and state funds—over the ten-year period outlined in the bill would reach almost $70 billion for hospitals in rural areas. 

Reductions in Medicaid funding of this magnitude would likely accelerate rural hospital closures and reduce access to care for rural residents, exacerbating economic hardship in communities where hospitals are major employers.

As a key insurer in rural communities, Medicaid provides a financial lifeline for rural health care providers — including hospitals, rural health clinics, community health centers, and nursing homes—that are already facing significant financial distress. These cuts may lead to more hospitals and other rural facility closures, and for those rural hospitals that remain open, lead to the elimination or curtailment of critical services, such as obstetrics.

“Medicaid is a substantial source of federal funds in rural communities across the country. The proposed changes to Medicaid will result in significant coverage losses, reduce access to care for rural patients, and threaten the viability of rural facilities,” said Alan Morgan, CEO of the National Rural Health Association.

“It’s very clear that Medicaid cuts will result in rural hospital closures resulting in loss of access to care for those living in rural America.”

A media briefing will be held on Tuesday, June 24, from noon to 1:00 PM EST to provide more information about the analysis. This event will feature representatives from NRHA, Manatt Health, and rural hospital leaders across the country. Questions may be submitted in advance, as well as during the press conference. To register for and join the media briefing, click on the Zoom link here.

Please reach out to NRHA’s Advocacy Team with any questions.

About the National Rural Health Association

NRHA is a non-profit membership organization that provides leadership on rural health issues with tens of thousands of members nationwide. Our membership includes nearly every component of rural America’s health care, including rural community hospitals, critical access hospitals, doctors, nurses, and patients. We work to improve rural America’s health needs through government advocacy, communications, education, and research. Learn more about the association at RuralHealth.US.

About Manatt Health

Manatt Health is a leading professional services firm specializing in health policy, health care transformation, and Medicaid redesign. Their modeling draws upon publicly available state data including Medicaid financial management report data from the Centers for Medicare and Medicaid Services, enrollment and expenditure data from the Medicaid Budget and Expenditure System, and data from the Medicaid and CHIP Payment and Access Commission. The Manatt Health Model is tailored specifically to rural health and has been reviewed in consultation with states and other key stakeholders.

What’s at stake from GOP megabill’s coverage losses

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, ACA, Bankruptcy, Chronic Care Management, Chronic Condition Management, Chronic Conditions, Chronic Diseases, Deferred Healthcare, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, High Deductible Health Plans, High Drug Prices, High Premiums, Medicaid, Medicaid Cuts, Medical Debt, Out of Pocket Expenses, Public Health, Underinsured, Uninsured • Tagged , , , , • Leave a comment

https://www.axios.com/2025/07/01/real-cost-health-coverage-losses

Nearly 12 million people would lose their health insurance under President Trump’s “big, beautiful bill,” an erosion of the social safety net that would lead to more unmanaged chronic illnesses, higher medical debt and overcrowding of hospital emergency departments.

Why it matters: 

The changes in the Senate version of the bill could wipe out most of the health coverage gains made under the Affordable Care Act and slash state support for Medicaid and SNAP.

  • “We are going back to a place of a lot of uncompensated care and a lot of patchwork systems for people to get care,” said Ellen Montz, a managing director at Manatt Health who oversaw the ACA federal marketplace during the Biden administration.

The big picture: 

The stakes are huge for low-income and working-class Americans who depend on Medicaid and subsidized ACA coverage.

  • Without health coverage, more people with diabetes, heart disease, asthma and other chronic conditions will likely go without checkups and medication to keep their ailments in check.
  • Those who try to keep up with care after losing insurance will pay more out of pocket, driving up medical debt and increasing the risk of eviction, food insecurity and depleted savings.
  • Uninsured patients have worse cancer survival outcomes and are less likely to get prenatal care. Medicaid also is a major payer of behavioral health counseling and crisis intervention.

Much of the coverage losses from the bill will come from new Medicaid work reporting requirements, congressional scorekeepers predict. Work rules generally will have to be implemented for coverage starting in 2027, but could be earlier or later depending on the state.

  • Past experiments with Medicaid work rules show that many eligible people fall through the cracks verifying they’ve met the requirements or navigating new state bureaucracies.
  • Often, people don’t find out they’ve lost coverage until they try to fill a prescription or see their doctor. States typically provide written notices, but contacts can be out of date.
  • Nearly 1 in 3 adults who were disenrolled from Medicaid after the COVID pandemic found out they no longer had health insurance only when they tried to access care, per a KFF survey.

Zoom out: 

The Medicaid and ACA changes will also affect people who keep their coverage.

  • The anticipated drop-off in preventive care means the uninsured will be more likely to go to the emergency room when they get sick. That could further crowd already bursting ERs, resulting in even longer wait times.
  • Changes to ACA markets in the bill, along with the impending expiration of enhanced premium subsidies, may drive healthier people to drop out, Montz said, skewing the risk pool and driving up premiums for remaining enrollees.
  • States will likely have to make further cuts to their safety-net programs if the bill passes in order to keep state budgets functioning with less federal Medicaid funding.

The other side: 

The White House and GOP proponents of the bill say the health care changes will fight fraud, waste and abuse, and argue that coverage loss projections are overblown.

Reality check: 

Not all insurance is created equally, and many people with health coverage still struggle to access care. But the bill’s impact would take the focus off ways to improve the health system, Montz said.

  • “This is taking us catastrophically backward, where we don’t get to think about the things that we should be thinking about how to best keep people healthy,” she said.

The bottom line: 

The changes will unfold against a backdrop of Health Secretary Robert F. Kennedy Jr.’s purported focus on preventive care and ending chronic illness in the U.S.

  • But American health care is an insurance-based system, said Manatt Health’s Patricia Boozang. Coverage is what unlocks access.
  • Scrapping millions of people’s health coverage “seems inconsistent with the goal of making America healthier,” she said.

Key Principles for Proactive Management of Patient Denials

Posted on by • Posted in Denial Management, Health Insurance Denial, Medical Denial Management, Medicare Advantage, Medicare Advantage Denials • Tagged , , , , • Leave a comment

https://www.kaufmanhall.com/insights/article/key-principles-proactive-management-patient-denials

The proliferation of claims denials, especially by Medicare Advantage payers, has become a pressing issue for health system operations. In 2023, Medicare Advantage insurers fully or partially denied 3.2 million prior authorization requests—or 6.4% of all requests, according to a Kaiser Family Foundation (KFF) report.

The growth in denials can be partially explained by the increasing popularity of managed Medicare and Medicaid plans, but evolving payer practices, including the adoption of AI for algorithmic denials, have also contributed. Claims denials have emerged as one of the key points of payer-provider tension, and an effective claims denials management and prevention program is a powerful way for health systems to rebalance their payer relationships.

Denied claims result in reduced reimbursement, added administrative burdens, and patient and provider frustrations. Even when denials are successfully appealed and reversed—the KFF report found that in 2023, 82% of Medicare Advantage denials were partially or fully overturned—the time and resources devoted to the appeals process add to the costs of providing healthcare services. Optimizing pre-billing activities to reduce avoidable denials and improve and streamline the patient experience of care is as essential for health systems as a robust appeals strategy. This article addresses critical success factors for both preventing and appealing denials.

Preventing Claims Denials During Pre-Bill Period

Successfully preventing denials requires a centralized program across the workforce, from frontline providers to clinical and revenue cycle staff, to manage pre-bill activities by focusing on identifying the correct patient insurance information, obtaining accurate authorizations, and preventing concurrent denials while the patient is still in the facility. Utilization review nurses, attending providers, and Physician Advisors should be attentive to documenting the full state of patient acuity, while collaborating with the revenue cycle team. This team should focus on the collection and reporting of medically necessary data and documentation, which serves as the evidence payers use to evaluate prior authorization requests. When information about a patient’s condition isn’t recorded, or acknowledged in an authorization request, unnecessary denials can result.

A successful denials prevention program expands beyond the utilization management (UM) team and includes revenue cycle, and provider collaboration. Revenue cycle pre-service procedures should focus on confirming insurance benefits and securing payer authorization for planned services while collaborating with UM and referral sources. A comprehensive and proactive denials prevention program helps conveys to payers the full extent of inpatient clinical work, thanks to a collaborative effort to improve documentation.

The following list can help organize denials prevention programs across all locations, clinics and practices:

  • Establish an enterprise-wide denials prevention strategy which includes a multi-disciplinary denials management committee focused on identifying denials trends, conducting root cause analyses, developing proactive denials mitigation plans, creating enhanced reporting, monitoring improvement, and communicating risk
  • Establish proactive revenue cycle, UM, pre-certification, and peer-to peer workflows procedures to confirm completion of payer requirements prior to scheduled services and discharge
  • Ensure patients are financially cleared through implementation of pre-service protocols, including enhanced medical necessity process for outpatient services, authorization defer and delay procedures to reduce rework and avoidable denials
  • Identify pre-bill edits to increase “clean claim” efficiency, reducing initial denials and expediting reimbursement
  • Deliver education to providers, care management, and nursing teams on key observation concepts, such as clinical documentation improvement, patient status documentation, medical necessity documentation and orders for the Two Midnights rule, and payer reimbursement methodologies

Pursuing Post-Bill Appeals, Reversals and Payer Escalation

A strong denials management and prevention program should include a robust post-bill appeals program with skilled coding, clinical and technical resources. A targeted and strategic appeal process can result in improved overturn rates and increased reimbursement. Appeal letters which are supported by clinical facts, payer policies, and a summary of key components relevant to each case and the associated denial increase the likelihood of success.

Components of the appeal program should include the following:

  • Guidelines for when to appeal based on potential success by payer and appeal level
  • Reviews of upheld appeals for second and third level appeals based on strategy by payer
  • Trends for all upheld appeals by reason and by payer
  • Dashboard for tracking denials activities
  • Appeal letter writing guidelines and tips to support
  • Evaluation process for existing payer escalation workflows, tools and payer communication strategies with consideration for payer
  • Process to measure and monitor overturn rates and improvement opportunities

The collaboration with managed care is vital to the success of the denials management/prevention program. A formal payer escalation process which facilitates transparency between the payer and provider can result in improved relations and a reduction in initial denials. Successful denials management/prevention payer escalation programs are strategic and focus on addressing unfair/incorrect denials and establishing clear bi-directional reporting and communications. These programs can result in improved contract negotiations and reduce incorrect denials.

Artificial Intelligence (AI) can support the post-bill appeals process and can be especially relevant when developing a strategy to combat denials. Not only are payers increasingly using AI to trigger denials, but health systems can also deploy AI to write appeal letters, analyze denial trends, and summarize medically necessary documentation. Although algorithmic denials have become a source of frustration for providers and patients, health systems can also deploy AI to their defense. While payers are often better positioned to devote AI resources to claims, a little bit of investment from health systems, deployed effectively, can go a long way toward evening the playing field.

Closing Thoughts and Seven Questions to Consider

A formal denials management and prevention program is essential to obtaining proper reimbursement for the care provided and reducing rework across the enterprise. A strong program should also improve the patient’s experience of care: ideally, a patient should not need to interact with or hear from their provider between scheduling an appointment and checking in.

Denials management and prevention programs should be led by multi-disciplinary committees and focus on reducing avoidable denials and rework. Reducing denials requires the implementation of a multi-disciplinary program and collaboration between UM, revenue cycle, clinical documentation improvement, managed care, clinical operation and providers. 

Health systems reassessing their claims denials program should consider these questions:

  1. Do you have a reactive or proactive denials management strategy in place?
  2. Does your denials strategy include multi-disciplinary team representation?
  3. What reporting/tools are currently being used to track and manage denials?
  4. What are your top five denial categories and what is being done to address the root cause of these denials?
  5. How are avoidable denial risks managed, communicated and monitored?
  6. Have you implemented a comprehensive denials management strategy with a multi-disciplinary committee?
  7. Are the system’s internal resources and expertise sufficient for addressing identified challenges, or should the system seek external partners to implement changes?

The 5 drivers pointing toward the decentralization of healthcare

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http://www.healthcaredive.com/news/decentralization-health-care-health-2-0-keynote/506377/

Health 2.0 co-chairs Indu Subaiya and Matthew Holt said these factors pose big questions to healthcare companies, including “What is your job in the new healthcare ecosystem?”

The decentralization of healthcare may be a great talking point and the ultimate end with patients at the fulcrum of care delivery business practices, but first, many hurdles need to be overcome.

Health 2.0 co-chairs Indu Subaiya and Matthew Holt outlined the five factors driving the decentralization of healthcare during their keynote address at the conference this week. They posed two big questions to healthcare companies, including, “What is your job in the new healthcare ecosystem?”

Holt and Subaiya shared their vision of where they see the industry going, mapping out the five drivers for the decentralization of healthcare:

  1. The new interoperability: With new standard protocols like FHIR and technology like blockchain, a new health IT paradigm could emerge where the monopoly of a user enterprise system (like an EHR platform) could disappear.
  2. Machine learning/artificial intelligence: Through the use of these tech tools, communication will change, leading to new form factors. The market has already seen the early spoils of this with products like Amazon’s Alexa and Google Home. Subaiya noted that, backed by the new interoperability, data transactions and services could become extensions of those new modalities.
  3. New entrants: One of the larger themes sprouting from 2017 is the looming question of, “What counts as a healthcare company now?” The short answer is all of them count. All of them are healthcare companies now. While that may be the cheeky answer, the fact, as Holt and Subaiya reminded the audience, is that many companies are looking into the digital health space. These new entrants are taking cues not from legacy healthcare companies but are bringing their own flavor, whether it’s offering customized nutrition plans or blending gym and healthcare business principles. What’s more, many of these companies are focused on consumer principles in an attempt to add a layer of stickiness to their core mission/product.
  4. Business model disruption: Early players in the space like Epic, Allscripts and Athenahealth have both seen changes in how they view their flagship products and all are prepping to adapt their offerings to a market that’s changed since they came to power. Largely, both consumers and clients want more functionality and capabilities to more easily interact with the products. The aforementioned new entrants are disrupting the business models for these legacy companies as well as changing the idea of what an entrant can be. Payer companies like Bright, Oscar and Clover, for example, are putting the customer at the center of their models and using technology not as an afterthought but as a core differentiator for operations.
  5. New environments: Healthcare and its care delivery services are increasingly being thought of outside of the four walls of traditional healthcare spaces. The prevailing innovative idea is to think of managing and preventing adverse health events by mixing and elevating a population’s environments. These new environments could express themselves in numerous ways such as rehabilitation parks. As Subaiya noted, health happens everywhere and these new environments could influence new players’ abilities to influence health.

The drivers that the presenters outlined point to a changing demographic where the patient is at the heart of care delivery services and wellness management while using new technology, a theme for which the conference is known for.

It’s a lot to take in, but Holt and Subaiya stated these new drivers require companies to ask of themselves “Who am I?”

For one, companies need to ask “What does value mean?” and, as Holt stated, not in the traditional venture capital way where a value proposition is another way to define why someone should give you money. Rather, what is the purpose and value a company is looking to add to the healthcare ecosystem, leading a company needing to answer “What is your new job in the new ecosystem?” Questions of who is the customer and what is the company’s job will be critical to navigate the healthcare business landscape going forward, especially since the environment is ripe for winners and losers in many facets of the industry.

While these thoughts are provocative about where the industry is heading, the business community of Silicon Valley and the policy makers in Washington, D.C., still need to recognize that those on the front lines of healthcare have a different perspective than a pie-in-the-sky take.

An article published in the new issue of Health Affairs found “hospitals’ use for patient care of data from outside providers was low, with only 18.7% of hospitals reporting that they ‘often’ used these data.”

“Our results reveal that hospitals’ progress toward interoperability is slow and that progress is focused on moving information between hospitals, not on ensuring usability of information in clinical decisions,” wrote the authors.

Thus, there may be a disconnect of current interoperability practices and where industry wants to go. The study plays on the tensions between end-users and health IT product makers, with both trying to navigate the end results to something usable and reliable.

Legacy EHR companies are looking to change. Epic is trying to incorporate more patient-sharing with Share Everywhere, for example. At Health 2.0, Allscripts CEO Paul Black stated the company is attempting to disrupt itself, or else others will come into the market and disrupt it for them. He added that Allscripts will soon be announcing different tools/offerings that seek to reimagine how a clinician interacts with a keyboard and how a patient interacts with an EHR.

Elsewhere at the conference, National Coordinator for Health IT Dr. Donald Rucker stated that new standards like FHIR and blockchain are still in an early stage of development. Technology changes in the healthcare space will largely be driven by consumers armed with apps that blend clinical data and lifestyle data. “That’s what the big drivers are and providers are sorting them out,” Rucker said.

The great technology dance between end-users, developers and policymakers continues on, but all seem to point to the need to keep the consumer at the forefront. Their businesses depend on it.