Many health plans are discovering that even after digitizing medical policies and implementing FHIR APIs, prior authorization turnaround times remain slow and provider frustration remains high. The reason is straightforward: digitization alone does not make medical‑necessity determinations executable by automated systems at scale.

The post Digitizing Medical Policy Alone Will Not Automate Prior Authorization at Scale appeared first on MedCity News.

While other areas of healthcare have been star-struck by sophisticated AI and massive infrastructure investments, safety net entities have found that the answer is much simpler. Better managing chronic conditions across populations simply requires the right connection at the right time. 

The post The Quiet Revolution Comes Full Circle: How CMS ACCESS Validates Safety-Net Innovation appeared first on MedCity News.

Healthcare interoperability isn’t an abstract concept; it’s about human connection, building trust and easing burden on patients and their care providers. 

The post Trust, Technology and the Future of Interoperability: Solving Problems That Impact Real Lives appeared first on MedCity News.

A consultant who has analyzed healthcare policy over many decades declares that MA is in the middle of a fundamental reset both in terms of market headwinds and federal scrutiny.

The post Policy Expert Believes CMS is Taking “Adversial Posture” to Medicare Advantage appeared first on MedCity News.

CMS is proposing to make its joint replacement bundled payment model mandatory nationwide. Experts say it is a logical step, but warn that mandatory participation could be challenging for hospitals to implement.

The post Expanding the CJR Model Is a Logical Step in VBC, but Implementation Challenges Remain appeared first on MedCity News.

CMS is rolling out its health tech ecosystem initiative with a new Medicare app library that functions like a healthcare “App Store,” aiming to make patient data more portable and accessible across vetted digital health apps.

The post CMS’ New ‘App Store’ Is Trying to Turn Interoperability Into a Digital Health Distribution System appeared first on MedCity News.

Some of the most powerful scenes aren’t the dramatic saves, but the quiet moments when clinicians connect with patients amid the chaos. Healthcare teams deserve access systems that allow for more of those moments.

The post What ‘The Pitt’ Gets Right About Emergency Medicine — and What It Reveals About Healthcare IT appeared first on MedCity News.

Rural health organizations cannot afford to get dazzled by AI demo candy. There is no such thing as “FixHealthcareGPT,” and investing in the wrong technology for the future isn’t going to do anything to improve patient outcomes today.

The post Rural Healthcare Transformation Has to Focus on the Real World, Not Techno-Fantasies appeared first on MedCity News.

Resource-sharing across large networks of hospitals allows people to receive a higher quality of care across the country, regardless of where they live or how well-resourced their local health system may be.

The post Not All Hospitals Have Equal Resources — Knowledge Sharing Can Help Level the Playing Field appeared first on MedCity News.

A group of 131 hospitals has sued HHS over a CMS policy they say improperly reduces Medicare disproportionate share hospital (DSH) payments. The lawsuit is the latest in a decade-long legal battle over how the agency counts patient days and calculates payments for safety net hospitals.

The post Why 131 Hospitals Are Suing HHS Over Alleged Underpayment appeared first on MedCity News.

Leaders must resist the urge to replicate urban models that do not translate well to rural contexts. Instead, they should design solutions that are built for rural communities, grounded in local insight and enabled by scalable capabilities.

The post A Once in a Generation Opportunity to Reimagine Rural Health appeared first on MedCity News.

If CMS and private payers are serious about whole-person health, reimbursement structures must align with the workforce actually delivering that care. Payment pathways should recognize the value of the broader care team and enable the seamless integration of their expertise with the objective data generated through connected devices and programs like RPM.

The post Behavior Changes Happen Outside the Exam Room, But Validation of Lifestyle Medicine Programs Cannot appeared first on MedCity News.

In the latest episode of the Debunked Podcast, the discussion revolved around the Break Up Big Medicine legislation to rein in healthcare giants and ways to introduce meaningful PBM reform.

The post Debunked Episode 24: PBM Reform Brainstorm, Elevance Faces CMS Penalty Risk, Hims & Hers’ Eucalyptus Deal Takeaways appeared first on MedCity News.

For providers, the rules mean more control over monitoring and the chance to keep a larger share of reimbursement. For device companies, they create a chance to show measurable value and guide clinicians through a system that is shifting quickly.

The post How New Medicare Rules Will Reshape Cardiac Monitoring and Remote Patient Care appeared first on MedCity News.

Further change in the Star Ratings program is inevitable, but one thing won’t change: plans that make targeted investments in improving the member experience and clinical outcomes, driven by data, are the most likely to succeed and achieve a higher overall rating.

The post 2026 Star Ratings Shift: 4 Strategies for MA Plans appeared first on MedCity News.

Technology alone won’t solve prior authorization. But refusing to adopt it guarantees the status quo: a system where insurers operate at machine speed, providers operate at human speed, and patients pay the price in delayed care.

The post Prior Authorization Is Broken. CMS’s New Rule Shows Why Regulated AI Is the Way Out appeared first on MedCity News.

At the end of the day, it doesn’t matter what your patient mix looks like; your notes can and will be pulled into audits. Waiting until CMS is at your doorstep isn’t a strategy — it’s a risk. Now is the moment to get ahead of it.

The post Why Providers Can’t Ignore CMS Audits appeared first on MedCity News.

Rainfall Health’s Series A round was led by Two Bear Capital. In total, the startup has raised $18 million.

The post Rainfall Health Raises $15M to Help Hospitals Navigate New CMS Model appeared first on MedCity News.

Organizations that excel don’t treat migrations as IT exercises. They treat them as compliance projects that require technical execution. Their methodology begins with regulatory obligations, builds technical architecture around them, and conducts relentless validation before calling the migration complete.

The post Proven Methodologies For Ensuring Seamless CRM Migrations In Highly Regulated Environments appeared first on MedCity News.

Healthcare cannot achieve its goals for quality, equity, and value without breaking down the persistent barriers that keep critical information siloed across sectors. 

The post The Next Frontier of Interoperability: Additional Clinical Data Sources – Dentistry, Devices, Social Care, and More appeared first on MedCity News.

The challenge for policymakers is balance: encouraging rigor without unintentionally weakening a program that now serves the majority of Medicare beneficiaries. Thoughtful rate calibration can determine whether this transition strengthens the program or strains it unnecessarily.

The post Medicare Advantage’s Discipline Era — and Why the Final Rate Notice Matters More Than It Appears appeared first on MedCity News.

We cannot wait for CMS to hand us perfect blueprints for rehab. The time is now for rehab leaders to define what optimized care looks like, build these pathways using evidence and outcomes data, and then aggressively demonstrate that our services are the most effective way to align with the new strategic direction of healthcare.

The post Optimizing Care Pathways: The Next Frontier in Rehab Performance appeared first on MedCity News.

Organizations can take steps now, in the early months of the program, to position themselves for success by evaluating past performance, identifying opportunities for improvement, and implementing episode-driven clinical and operational workflows.

The post TEAM is Here, and Hospitals Are Running Out of Time to Prepare appeared first on MedCity News.

This week, Congress reached a bipartisan healthcare deal as part of a larger $1.2 trillion spending bill, combining funding increases, policy reforms and program extensions. The proposal maintains key programs like CMS coverage for telehealth and hospital-at-home care, but stops short of renewing enhanced ACA premium tax credits.

The post Congress’ New Healthcare Package: 7 Things to Know appeared first on MedCity News.

A unified workflow for all referrals, resulting in fewer clicks and less confusion, means provider matching can be conducted based on specialty, location, insurance, and real-time availability, for an easier track to the right provider, not just any provider.

The post TEAM Success Depends on How Well a Hospital Ensures Medicare Patients Get the 30-Day Episode of Care They Need appeared first on MedCity News.

Upended by chronic diseases and community realities, healthcare needs to shift its priorities to post-acute environments.

The post Healthcare Information Sharing Must Expand Beyond Its Hospital-Centric Focus appeared first on MedCity News.

We are currently experiencing an inflection point for progress in interoperability. Without meaningful reform to reflect the real world, the system risks repeating and even accelerating historical patterns of exclusion — leaving vulnerable patients behind.

The post Making Interoperability Privacy Standards Work for the Real World appeared first on MedCity News.

CMS has introduced the MAHA ELEVATE model to expand lifestyle medicine in Medicare, a move experts support but say will hinge on effective implementation.

The post What Health Experts Are Saying About the MAHA ELEVATE Program appeared first on MedCity News.

CMS’ new ACCESS model, slated to begin on July 1, aims to shift traditional Medicare fee-for-service toward value-based care by tying payments to patient outcomes and encouraging tech-enabled, preventive care. Experts say it could benefit digitally mature, value-focused providers first, but its overall success will hinge on clear metrics, better data sharing and sustained participation.

The post CMS’ ACCESS Model: A New Push to Rewire Medicare Around Outcomes? appeared first on MedCity News.

With new therapies being approved, and many others in the pipeline, they raise a critical question: Is our healthcare system prepared to deliver them effectively and sustainably?

The post Breakthrough Therapies Aren’t Enough: What Neurology Needs Now appeared first on MedCity News.