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Author: Lauren Brown

Aetna delays new inpatient severity-level payment policy to 2025

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Aetna has postponed the rollout of its new “level of severity inpatient payment” policy for Medicare Advantage members, moving it from Nov. 15 to early next year. Under this approach, Aetna will automatically approve certain inpatient stays—without a medical necessity review—but pay them at a lower severity rate similar to observation status unless the stay meets Aetna’s additional inpatient criteria. The policy applies to affiliated Medicare facilities and focuses on urgent or emergent admissions lasting…
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Regional Medical Center of Central Alabama to end inpatient care as it pursues rural emergency hospital status

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Regional Medical Center of Central Alabama (RMCCA) in Greenville has announced plans to discontinue inpatient services and lay off roughly 90 employees as part of a major restructuring effort. The hospital’s board unanimously approved transitioning to a rural emergency hospital (REH) — a federal designation meant to help rural facilities stay open by focusing on emergency, outpatient, and limited on-site services rather than traditional inpatient care. According to RMCCA, the shift is driven by ongoing…
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Severe flu outbreaks across globe spur warnings for US

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Countries across the globe are reporting an unusually early and intense start to flu season, driven by a newly mutated version of the H3N2 influenza A strain. This strain, which tends to cause more severe illness—especially in older adults and young children—picked up multiple mutations over the summer. Because of these changes, it differs from the H3N2 component included in this year’s flu vaccine. The impact has been significant overseas: Experts say these trends are…
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U.S. Antibiotic Awareness Week (USAAW) Toolkit

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The U.S. Antibiotic Awareness Week (USAAW), is every November 18-24. The theme for the 2025 USAAW 2025 “Fighting Antimicrobial Resistance Takes All of Us.” The USAAW raises awareness of the importance of appropriate antibiotic and antifungal use and the threat antimicrobial resistance (AR) poses to people, animal, plants, and their shared environment. Check USAAW for daily tips this week, but also a great resource to refer back to throughout the year.

Alabama Hospitals Rank Among the Shortest ED Wait Times for Mental Health Patients

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New data from CMS’s Timely and Effective Care–Hospital dataset highlights national trends in emergency department (ED) wait times for psychiatric and mental health patients, and two Alabama hospitals ranked among the best in the country. The dataset, released August 6, evaluates ED visits from January through December 2023 and measures the median length of stay for mental health patients. Nationally, the median ED visit time was 271 minutes, up slightly from 267 minutes the previous…
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Medicare Participation Reminder for CY 2026: Decisions Due by December 31

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As the new year approaches, CMS is reminding physicians, practitioners, and suppliers to review their Medicare participation status for Calendar Year (CY) 2026. All providers must finalize their decision by December 31, 2025. Why Participation Matters Choosing to participate in Medicare offers several key advantages: Who Doesn’t Need to Take Action? No action is needed if you: Providers who want to change their Medicare participation status should visit CMS’s Annual Medicare Participation Announcement page for…
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CMS Finalizes 2026 Medicare Physician Fee Schedule: Key Updates & Reimbursement Changes

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CMS has released its final rule for the 2026 Medicare Physician Fee Schedule, including major reimbursement changes, updated conversion factors, and policy shifts affecting physician practices, ACOs, and specialty care models. 1. Two Separate Conversion Factors For 2026, CMS will use two different conversion factors: 2. New Conversion Factor Amounts 3. What Drives These Increases Each conversion factor reflects: 4. New 2.5% Efficiency Adjustment CMS finalized a –2.5% efficiency adjustment to work RVUs and physician…
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Teva Recalls Over 580,000 Bottles of Blood Pressure Medication Due to Impurity Concerns

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Teva Pharmaceuticals has issued a voluntary recall of more than 580,000 bottles of prazosin hydrochloride, a commonly prescribed blood pressure medication, after routine quality testing detected a nitrosamine impurity known as N-nitroso Prazosin impurity C. According to the FDA, long-term exposure to nitrosamines above established limits may increase the risk of cancer. The recall has been designated as Class II, meaning the likelihood of serious adverse health effects is considered remote, but temporary or medically…
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10 Key Things Providers Should Know About the Stark Law

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The Stark law remains one of the most significant federal regulations governing financial relationships in healthcare. It aims to prevent fraud and abuse by prohibiting physician self-referrals for certain Medicare and Medicaid services. A recent overview from the law firm Eisner Gorin highlights several important updates and reminders for providers. What the Stark Law Covers The law bars physicians from referring Medicare or Medicaid patients for designated health services to any entity with which they…
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CMS Publishes 2026 Policy Changes for the Quality Payment Program

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The Centers for Medicare & Medicaid Services (CMS) has released the 2026 Medicare Physician Fee Schedule (PFS) Final Rule, outlining updates to the Quality Payment Program (QPP) for the 2026 performance year and beyond. The rule will be officially published on November 5, 2025, in the Federal Register. CMS emphasized program stability while continuing the shift toward MIPS Value Pathways (MVPs) and greater alignment across programs. Merit-based Incentive Payment System (MIPS) MVPs (MIPS Value Pathways)…
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Blue Cross and Blue Shield of Alabama: Upcoming Drug Policy Updates

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Effective January 1, 2026, prior authorization will be required for all denosumab products, including biosimilars, for commercial Blue Cross of Alabama members. For PEEHIP plans, beginning October 1, 2025, the same preferred products apply. All other denosumab versions will be non-covered, with proactive authorizations added for current patients. Additional PEEHIP medical drug updates (effective Jan. 1, 2026) include changes to coverage and preferred products across multiple drug classes, such as myasthenia gravis therapies, pegfilgrastim, trastuzumab,…
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New CMS Model Aims to Cut Prescription Costs and Expand Access in Medicaid

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The Centers for Medicare & Medicaid Services (CMS) has introduced a new initiative aimed at lowering prescription drug costs and improving access to critical medications for Medicaid beneficiaries. The GENErating cost Reductions fOr U.S. Medicaid (GENEROUS) Model, set to launch in 2026, will allow participating states to purchase certain drugs at internationally competitive prices to reduce spending and promote affordability. The model encourages state Medicaid programs and drug manufacturers to collaborate on transparent, uniform pricing…
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