Final rule is intended to hold health insurance companies to higher standards.
The final rule issued recently by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services (CMS) will ensure that Medicare Advantage (MA) plans work for seniors and people with disabilities.
By cracking down on misleading marketing schemes, removing barriers to care, expanding access to behavioral health care, and promoting health equity, this new rule will strengthen Medicare Advantage and hold health insurance companies to higher standards.
Moreover, implementing a key provision of the Inflation Reduction Act will improve access to affordable prescription drug coverage for an estimated 300,000 low-income individuals. This is a significant step towards improving healthcare for all Americans, especially for those who are most vulnerable.
Under the new rule, advertisements for Medicare Advantage and Part D plans must mention a specific plan name and may not use the Medicare name, CMS logo, or other information issued by the Federal Government in a misleading way. The rule also increases accountability for plans to monitor the activities of agents and brokers who sell Medicare plans.
Overall, the changes outlined in the final rule aim to improve transparency and accountability in the marketing of Medicare Advantage and Part D plans, which could help individuals make more informed decisions about their healthcare coverage.
Also under the new rule, a granted prior authorization approval must remain valid for as long as it is medically necessary to avoid disruptions in care. Medicare Advantage plans will also be required to conduct annual reviews of their utilization management policies to ensure they are up to date and effective. In addition, health care professionals with relevant expertise must review denials of coverage based on medical necessity before a denial can be issued.
These changes are intended to complement proposals in CMS’ Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (CMS-0057-P), which seeks to improve the electronic exchange of health information and streamline the prior authorization process through greater standardization and automation.
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Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.
Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.
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