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Thursday, October 1 · 46 stories
- Industry
Aspirion Pitches AI Tool to Find Patterns Behind Clinical Denials
In a Becker's Hospital Review piece, Aspirion executives argue that hospitals focused only on overturning individual clinical denials miss the recurring patterns driving them, and promote the company's AI-enabled "ClinIQ" platform as a solution. The piece cites Kodiak Solutions data showing revenue leakage across more than 2,300 hospitals rose about 25% in 2025 to $48.4 billion, driven partly by clinical denials tied to medical necessity, and a survey finding 76% of revenue cycle leaders expect denial rates to keep rising. Aspirion frames denials as falling into two categories, payer behavior versus provider documentation gaps, and says its tool helps health systems distinguish the two at scale and route insights to CDI, utilization management, and managed care teams. Aspirion reports its clients see appeals filed 2.2 times faster and a 64% resolution rate using this approach.
- Industry
State Officials Press for Scrutiny of Hospital Megamergers
Minnesota Attorney General Keith Ellison is reviewing HealthPartners' proposed acquisition of Essentia Health, a deal that would create a 22-hospital nonprofit system with roughly 45,000 employees, and is seeking public input under state healthcare, charities and antitrust laws. In North Carolina, State Treasurer Brad Briner has called on the state attorney general and federal regulators to scrutinize Atrium Health's proposed combination with WakeMed Health & Hospitals, citing concerns about prices, competition and access. Both deals exemplify a broader wave of cross-market "megamergers" as systems seek scale, diversified risk and stronger payer leverage instead of same-market deals that draw heavier antitrust review. Kaufman Hall data shows two-thirds of Q2 hospital transactions involved independent systems seeking partners from positions of strength rather than financial distress, signaling consolidation is accelerating even among stable organizations.
- Federal Policy
HRSA Names Manufacturers Approved for Expanded 340B Rebate Pilot
HRSA has disclosed which drug manufacturers are approved to participate in a revised 340B rebate pilot, under which ten drugmakers will shift 21 drugs from upfront discounts to after-the-fact rebate payments starting next year. The change expands on the administration's earlier rebate pilot attempt. Covered entities purchasing these drugs through 340B will need to pay full price at the point of sale and later seek rebates, rather than receiving discounts immediately. The shift takes effect at the start of next year.
- Industry
MACPAC Awards Acumen 10-Year Medicaid Data Analysis Contract
MACPAC, the nonpartisan legislative branch agency that advises Congress on Medicaid and CHIP policy, has awarded an indefinite delivery indefinite quantity contract to Acumen, LLC for analysis and management of administrative data. The contract, posted to SAM on May 28, 2026 under Notice ID 202601, covers fiscal years 2027 through 2036. The award supports MACPAC's ongoing work analyzing Medicaid and CHIP administrative data to inform the Commission's policy analysis and recommendations to Congress.
- State Policy · CA
California Enacts AI Clinical Judgment and Bias Safeguards for Healthcare
Gov. Gavin Newsom signed AB 1979 and SB 503 on Sept. 30, establishing new safeguards that protect physicians' and licensed providers' professional judgment when AI or clinical decision tools are used in patient care, and requiring AI developers to take reasonable steps to reduce known or predictable bias in those tools. The laws are part of a broader package addressing AI's role in workplaces and consumer protection. Newsom vetoed a related bill, AB 2575, which would have barred retaliation against healthcare workers who override unsafe AI recommendations; the California Nurses Association criticized the veto. The California Hospital Association said it no longer opposes AB 1979.
- Industry · CA
CommonSpirit Narrows Operating Loss, Books $2.3B Conifer Exit Charge
CommonSpirit's fiscal 2026 financial report shows an operating loss of $430 million (-1.0% margin) excluding special charges, improved from a $687 million loss the prior year. Including $2.8 billion in special charges, largely a $2.3 billion hit tied to exiting its Conifer Health Solutions revenue cycle venture, plus a tradename impairment and restructuring costs, the system's total operating loss was $3.2 billion. Revenue grew 8.5% to $42.4 billion, helped by $991 million in California Provider Fee Program net income, up sharply from $305 million the year before. The 136-hospital system posted a net loss of $662 million for the year, compared to $1.1 billion in net income in fiscal 2025.
- Federal Policy · AL
CMS Awards Nearly $55 Million for Rural Maternal, Emergency Care
CMS announced nearly $55 million in new federal funding to expand rural maternal health services, emergency care, cancer screening, and healthcare workforce development, with a specific focus on Alabama's rural healthcare workforce. The funding is aimed at rural hospitals and providers facing access gaps in obstetric and emergency services. The announcement does not specify the exact award mechanism or full list of recipient states beyond Alabama's workforce component. Rural Medicaid beneficiaries, who rely heavily on these facilities for maternal and emergency services, stand to benefit from expanded capacity and workforce investment.
- Legal
Court Strips Integration Mandate From Section 504 Rules
A federal judge in Texas v. Kennedy agreed to remove "most integrated setting" language from Section 504 regulations after the Justice Department, originally the defendant, switched sides to side with states challenging the rule. The reversal follows a June DOJ opinion disavowing the integration requirement and a July announcement that DOJ would stop relying on its enforcement guidance. Disability rights advocates say the ruling does not undo ADA or Olmstead protections but creates legal ambiguity that could let states scale back community-based services, particularly as states face pressure to cut Medicaid spending. Advocacy groups are now backing legislation to codify integration protections and working with states directly to strengthen disability laws.
- State Policy · WI
Federal Immigration Cuts Worsen Wisconsin Long-Term Care Staffing Crisis
Reductions in refugee admissions and Temporary Protected Status under the Trump administration have halted overseas recruitment pipelines that Wisconsin long-term care facilities relied on to fill caregiver positions. The resulting labor shortage has forced some facilities to close long-term care beds, reducing capacity for residents who depend on these services, many of whom are covered by Medicaid. The cuts affect nursing homes and other long-term care providers statewide that have struggled for years with chronic direct-care workforce shortages. The story reports an ongoing crisis rather than a single new policy action, reflecting the compounding effect of federal immigration policy on state long-term care capacity.
- State Policy · PA
Pennsylvania House Advances Menopause Treatment Coverage Bill Package
Pennsylvania House committees have advanced seven bills addressing perimenopause and menopause care, including measures from Reps. Liz Hanbidge and Morgan Cephas that would expand Medicaid and private insurance coverage for hormonal and non-hormonal menopause therapy and pelvic floor therapy. Other bills in the package address provider education partnerships with the Department of Health and workplace accommodations for menopausal symptoms. Some Republicans opposed the measures over concerns about increased Medicaid costs. The bills are still moving through House committees, with no final floor votes or effective dates yet reported.
- Industry
States, Hospitals Expand Automatic Enrollment in Charity Care
A Tradeoffs/KFF Health News explainer describes how hospitals use "presumptive eligibility" to automatically screen patients for charity care and wipe out medical bills without requiring a formal application. Nonprofit hospitals increasingly use this approach to comply with ACA requirements to identify financial-assistance-eligible patients before pursuing debt collection, with screening rates rising from about 70% to nearly 90% of tax-exempt hospitals since 2016. Six states, California, Delaware, Illinois, Maryland, North Carolina, and Oregon, mandate presumptive eligibility for certain patient groups, though criteria vary widely and remain difficult for patients to find. For-profit and public hospitals are not subject to the federal reporting requirement, leaving gaps in who benefits from automatic debt relief.
- Industry
KFF Health News Minute Roundup Covers Medicaid Meal Pilots, Work Rules
KFF Health News publishes weekly "KFF Health News Minute" audio digests summarizing original health policy reporting. Recent episodes touch on Medicaid-relevant topics, including states piloting medically tailored meal delivery programs to reduce costs and improve outcomes, concerns from doctors about certifying patient exemptions under new Medicaid work requirements, and warnings that homeless enrollees will need to document work activity to retain coverage. The digest format compiles brief summaries of multiple unrelated health stories each week rather than reporting a single new policy action. No specific effective dates, agency actions, or regulatory changes are detailed in the segments themselves.
- Legal
Law Firm Assesses Six Months of CMS Home Health Enrollment Moratorium
In a client alert, Arnall Golden Gregory LLP reviews the first six months of CMS's enrollment moratorium on home health and hospice agencies, imposed in May 2026 under the agency's CRUSH anti-fraud initiative. The firm examines how the moratorium has affected provider enrollment, M&A transactions, and agency growth in the sector, addressing industry concerns raised when the policy was first announced. The analysis covers practical impacts on providers and investors navigating the enrollment freeze. No new CMS action is reported; the piece is a retrospective legal analysis of an existing policy.
- Federal Policy
CMS Updates MDS Coding Guidance, Discharge Rules Still Unclear
CMS has issued updates to the MDS 3.0 Resident Assessment Instrument manual that address a long-standing provider concern: documentation demands during state case-mix audits and medical reviews that are often additional or conflicting. Nursing home operators and industry observers describe the coding changes as a significant win for providers, though questions remain around discharge coding clarity. The updates are due to be implemented, though the source does not specify a firm effective date. Nursing facilities, Medicaid case-mix states, and auditors handling MDS-based reviews will need to adjust documentation and audit practices once the guidance takes effect.
- State Policy · NE
Nebraska Counties Route Opioid Settlement Funds to Regional Authorities
Nebraska counties receiving opioid settlement payments are increasingly directing those dollars to regional behavioral health authorities rather than managing substance abuse programs independently, according to the report. These authorities are seen as better equipped to administer treatment and prevention services than individual county governments. The trend reflects how localities are distributing a multi-year stream of settlement funds from opioid litigation. No specific timeline or dollar figures for the shift were detailed in the report.
- State Policy · WI
Milwaukee Free Clinic Braces for Surge of Uninsured Patients
Bread of Healing Clinic, which provides free and low-cost care to Milwaukee residents, is preparing for an increase in uninsured patients following changes to Medicaid eligibility. The clinic is asking the community for additional support to handle the anticipated demand. No specific timeline or dollar figures are given in the report, but the clinic frames the shift as a direct consequence of recent Medicaid policy changes affecting coverage access.
- Industry
Lawyers Warn AI Fraud Tools Lack Human Oversight in Hospice Audits
In a two-part investigative series, Hospice News reports that legal experts are raising concerns about insufficient human oversight in AI-driven hospice fraud enforcement. Attorneys Edo Banach (Foley Hoag) and Howard Young (Morgan Lewis) say CMS contractors are using AI tools to select hospices for audit and process rebuttals, sometimes producing responses with apparent AI "hallucinations" that get reversed once humans review them. CMS's proposed CRUSH initiative, along with AI-driven data mining by the FBI, HHS-OIG, and DOJ's National Fraud Detection Center, are scrutinizing billing anomalies like long lengths of stay and high recertification volumes, with recent revocations concentrated in Arizona, California, Nevada and Texas. CMS did not respond to requests for comment on its AI oversight practices.
- Industry
Elevance Moves to Curb Hospital Billing for Off-Campus Care
Elevance Health is implementing a policy to restrict hospitals from charging facility fees or higher reimbursement rates for services delivered at off-campus outpatient departments, aiming to align payment with site-neutral principles. Hospital groups oppose the move, arguing the reimbursement reductions could jeopardize patient access to care, particularly in markets where hospital-owned outpatient clinics are prevalent. The policy affects hospitals and health systems contracted with Elevance across its commercial and potentially Medicaid managed care lines. Details on effective dates and scope across Elevance's state Medicaid contracts were not specified.
- Industry · OR
Oregon Candidate Beck Makes Rural Medicaid Cuts Campaign Issue
Democrat Chris Beck, challenging Republican Rep. Cliff Bentz in Oregon's 2nd Congressional District, is campaigning on protecting rural health care from Medicaid cuts included in the 2025 federal tax and spending law (H.R. 1). Beck argues the law, which Bentz supported, could cause rural hospitals to lose Medicaid reimbursements as patients lose coverage, calling it a potential "financial death knell" for rural facilities. He is calling for repeal of the law and voiced support for a national health system modeled on the Oregon Health Plan that would guarantee basic and preventive care. Bentz did not respond to an interview request; the race is ongoing ahead of the 2026 election.
- Legal · WI
Judge Strikes Down Trump Rule Requiring Immigration Checks for Federal Services
A federal judge ruled Sept. 21 that the Trump administration's 2025 rule requiring immigration status checks for users of federally funded adult education, Head Start, and community health centers violated notice-and-comment requirements. The rule would have barred undocumented immigrants and several legal-status categories, including TPS holders and U visa applicants, from these programs, reversing a three-decade interpretation that such safety-net services were open to all regardless of immigration status. Wisconsin and 20 other states had sued to block the rule, arguing it would force states to restructure social safety nets and render them inaccessible to vulnerable residents. The ruling permanently blocks enforcement of this version of the rule, though federal agencies could reissue it after proper notice and comment.
