Since its inception, AI in prior auth has only been at work in the commercial healthcare marketplace. Now new innovative approaches that reframe prior auth as a resource instead of a roadblock have come to Medicare via the WISeR model.

The post ‘Prior Authorization’ Has Become a Dirty Word in Healthcare, But it Might Be Medicare’s Smartest Path Forward appeared first on MedCity News.

Healthcare has solved for the hard part. The science, the surgery, the diagnosis: by global standards, we’re exceptional.
What we haven’t solved for is what happens when the patient goes home.

The post The Healthcare Industry Has a Last Mile Problem — It Hasn’t Realized It Yet appeared first on MedCity News.

New research from the Elevance Health Public Policy Institute finds that higher enrollment in Medicare Advantage may be linked to lower overall Medicare spending.

The post Report: Growth in MA Is Associated With Lower Total Medicare Spending appeared first on MedCity News.

Chapter’s Series E round was led by Generation Investment Management, with participation from Fifth Down Capital, 8VC, Stripes, XYZ Venture Capital, Addition, Narya Capital, Susa Ventures and Maverick Ventures.

The post With $100M Raise, Chapter Targets Medicare Mismatches for Seniors appeared first on MedCity News.

Over the past 15 years, financial and administrative barriers – most notably step therapy mandates and prior authorization requirements – have repeatedly forced patients through suboptimal or ineffective treatments before they can try another therapy, have tied the hands of healthcare professionals and patients alike. Now there’s a possible solution.

The post Join the Fight Against Chronic Pain: It’s Time for Breakthrough Legislation in Congress 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.

The specialty access and capacity crisis demands more than incremental fixes. It requires expanding virtual access and fundamentally rethinking how specialty care can be delivered.

The post Virtual Specialty Care Has Time. Will We Use It Wisely? 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.

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 have to cover medical nutrition therapy for those who need it most, including Medicare beneficiaries. Almost all commercial payers are already doing this – the government needs to catch up.

The post Medicare Is Covering GLP-1s – It’s Time to Cover the Care That Makes Them Sustainable appeared first on MedCity News.

The American Medical Association is urging Congress to permanently extend Medicare’s pandemic-era telehealth flexibilities, warning that temporary extensions create uncertainty for patients and providers.

The post AMA to Congress: Make Medicare Telehealth Services Permanent 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.

Here are three things providers should consider when it comes to Medicare.

The post Changes Are Coming to 2026 Medicare Benefits appeared first on MedCity News.

Thirteen House Democrats introduced eight bills to rein in Medicare Advantage and bolster traditional Medicare.

The post Lawmakers Introduce Multiple Bills Aimed at Medicare Advantage Reform appeared first on MedCity News.

Pluto Health is now working with Medicare, Medicaid and commercial plans like UnitedHealthcare, Aetna, Blue Cross Blue Shield, Ambetter and Cigna.

The post Pluto Health Expands Care Model to Medicare, Medicaid and Major Commercial Plans appeared first on MedCity News.

The bill clarifies very specific patient protections and codifies a Patient’s Bill of Rights, all of which would ensure that individuals receiving supplemental oxygen in the home – and their suppliers – understand requirements around equipment, communications, and care options. 

The post SOAR Act Would Help Individuals Relying on Oxygen Thrive appeared first on MedCity News.

We need a national strategy to expand access to palliative care, train the next generation of clinicians, and build the infrastructure that allows for scalable, tech-enabled, patient-centered delivery.

The post The Hidden Crisis in Serious Illness Care and How We Fix It appeared first on MedCity News.

Physicians are facing rising workloads, shrinking support staff and declining reimbursement — resulting in a burnout crisis and threatening the sustainability of independent practices. Experts say urgent Medicare payment reforms are needed to prevent further consolidation, as well as preserve access to care.

The post Workload Up, Payment Down: The Growing Strain on Independent Practices appeared first on MedCity News.

[Sponsored] Turn complex healthcare data into clear, context-rich insights that drive faster, smarter decisions.

The post Transforming Healthcare Through Contextualized, Decision-Ready Insights appeared first on MedCity News.

A group of healthcare organizations sent a letter to Congressional leaders urging them to permanently extend Medicare telehealth flexibilities introduced during the Covid-19 pandemic.

The post 350 Healthcare Organizations Call for Extension of Medicare Telehealth Access appeared first on MedCity News.

Drastic cuts to Medicaid and Medicare proposed by Congress will increase wait times, result in more fragmented or nonexistent care, and cause unnecessary deaths and despair.

The post For the Sake of their Constituents, Congress Should Increase Medicare Payments and Oppose Deep Cuts to Medicaid appeared first on MedCity News.

To remain resilient amid the volatility, skilled nursing facilities need to stay on top of what’s impacting operations and consider strategic opportunities. Here are important trends to watch. 

The post Industry Pressures and Possibilities: What’s Ahead for Skilled Nursing Facilities appeared first on MedCity News.

As scrutiny from CMS and the FCC increases, Medicare marketers must rethink how they source, verify, and engage leads. Taking the focus off lead volume and redirecting it to lead quality will help them demonstrate they run an ethical operation.

The post Lead Quality vs. Lead Volume: What Matters Most When Serving Vulnerable Populations appeared first on MedCity News.

Oral diseases cost Americans almost $140 billion annually. What will it take to bring these costs down?

The post If We Treated Tooth Decay Like We Treat Heart Disease, We’d Save Billions appeared first on MedCity News.

The combination of coverage awareness and care navigation powered by agentic AI has the potential to transform how older adults engage with the healthcare system.

The post The Age of Action: Seizing CMS’s Call to Reimagine Medicare appeared first on MedCity News.

Earlier this month Sachin Jain, CEO of SCAN Health Plan, a nonprofit Medicare Advantage company, provided some refreshing straight talk on what is wrong with MA while stressing that it is far better than traditional Medicare for seniors.

The post Medicare Advantage CEO: My Baby is Ugly…(video) appeared first on MedCity News.

At Medicarians 2025, MedCity News Editor-in-Chief Arundhati Parmar explored the state of AgeTech venture capital with three investors. The panelists agreed that despite growing clear opportunities, the AgeTech market currently lacks the dedicated funding, proven business models and major success stories needed for it to take off.

The post Where Does AgeTech Investment Stand?: VCs Weigh Promise Against Payout appeared first on MedCity News.

This is not just about today’s older adults — it’s about the next 50 years. If we design a smarter, more sustainable system now, we will all benefit when our time comes.

The post America’s Aging Crossroads: Will We Rise to the Challenge or Fall Behind? appeared first on MedCity News.

They work in neighborhood clinics, community-based organizations, churches, housing facilities, and schools, or engage by phone or video calls. Their approach is based on local context and guided by culturally sensitive, person-centered strategies. 

The post Empowering Community Health Workers: The Unsung Heroes Transforming Healthcare   appeared first on MedCity News.

Reporting quality on all beneficiaries marks a major shift, requiring thoughtful preparation and strategic planning. If your Accountable Care Organization (ACO) hasn’t started yet, don’t worry — there’s still time to get on track.

The post Late to APP Reporting? Untangle Your ACO’s Optimal Method appeared first on MedCity News.