In what feels like a final drive to exercise authority prior to the election, and a potential shift in control of the presidency and administration, over the last month the federal government has taken several steps to enhance oversight and regulation in the healthcare sector.
These actions reflect what the current administration hopes will be viewed as efforts to make good on commitments to protect consumers and ensure fair practices in the rapidly evolving landscape of healthcare services, in areas ranging from the Affordable Care Act (ACA) exchanges to healthcare company mergers and acquisitions to mental health parity.
For example, it seemed notable last week when the Centers for Medicare & Medicaid Services (CMS) released a proposed rule to empower the agency to review and suspend health insurance agents and brokers for violating rules on enrolling beneficiaries in ACA plans. These brokers, also known as marketers, operate within the ACA marketplace to assist consumers in selecting health insurance plans from the federal exchanges.
According to some experts, CMS wants to be seen taking a firmer stance against health insurance marketers that fraudulently switch exchange enrollees’ plans without their consent. CMS notes that many of these brokers operate with minimal oversight, which can lead to misinformation and a lack of transparency in choices presented to consumers.
This comes as CMS announced last month that it would continue monitoring agents for marketplace fraud after receiving over 200,000 complaints in the first half of the year.
The proposed rule also contains provisions requiring ACA insurers to review networks for certain providers, offer multiple standardized plans, and pay increased user fees.
On the antitrust front, a final rule recently approved by the Federal Trade Commission (FTC) aims to prevent anti-competitive practices that can arise from industry consolidation. Healthcare companies pursuing mergers and acquisitions will be required to submit additional information about their proposals when the rule goes into effect, likely next year.
These companies, when involved in such proposals, will have to list other acquisitions that occurred within the last five years, disclose private equity stakeholders with decision-making authority, and report supplier relationships shared by the merging parties to the FTC. According to the FTC Chair, the rule “will provide antitrust agencies with probative intelligence as to whether a proposed deal risks violating antitrust laws.”
However, it will likely take time to see how the guidelines laid out in the rule, which are not legally binding, will be adhered to by companies and interpreted by the courts.
Meanwhile, last month, the U.S. Department of Health and Human Services (HHS), in conjunction with the Labor and Treasury Departments, issued new mental health parity standards to address what HHS has suggested is a pattern by health plans of imposing stricter limits on mental health coverage. As such, the regulation finalized requirements for health plans to cover mental health and substance use disorder services to the same degree they cover medical benefits, and to develop comparative analyses to inform coverage improvements.
It also eliminates “discriminatory practices such as higher co-pays, restrictive treatment limits, and lower reimbursement rates” for mental health providers, which means that in order to comply, health plans may need to add more mental health providers to their networks, markedly raise reimbursements, or curtail prior authorization constraints.
In sum, recent crackdowns by the feds signal the intent to enhance healthcare regulation and consumer protection priorities before time expires on the Biden Administration. We’re seeing this play out via stricter rules, tighter scrutiny, and more complex, onerous requirements in areas of healthcare that have been recognized for their importance to the larger industry.
As these regulations take shape, they are likely to have lasting impacts on the quality and accessibility of healthcare, fostering what the government hopes will be a more informed and empowered consumer base before a new administration comes in.
Literature is ripe with classic phrases that seem timelessly apropos. For example, take the partial federal government shutdown. For days, the phrase repeated in the
As we approach the holidays and look back on the past year we had and look forward to the new year and new presidential administration,
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
Copyright © 2025 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
