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Lindsay Burrows is an associate attorney at Wolfe | Pincavage

It has been a record year for healthcare claim denials and underpayments, often leaving providers to foot the bill. Here are 10 suggestions to help providers avoid preventable denials.

Talk 'data' to me: Why aren’t your healthcare claims getting paid? | Lindsay Burrows

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Just two weeks before telehealth waivers are set to expire, Congress has shown support for an extension of virtual care programs.

 to fund government programs into March, and telehealth advocates said a spending plan included measures to extend telehealth programs.

The package included a two-year extension for most telehealth programs, and a five-year extension for hospital-at-home programs, according to the American Telemedicine Association.

Congress approved broad extensions of telehealth programs early in the telehealth pandemic, but those waivers were set to expire Dec. 31.

Telehealth advocates and a broad array of healthcare providers 

have been pressing Congress and President Biden’s administration

 to approve an extension of telehealth programs. They’ve been increasingly anxious as the end-of-year deadline has approached.

Lawmakers have also been grappling with another pressing deadline, as government agencies will shut down Friday night without new spending legislation. 

Now, uncertainty looms with the collapse of a deal on the overall spending bill. Republicans aren't supporting the temporary spending bill after President-elect Donald Trump and Elon Musk denounced the deal, as 

Kyle Zebley, the senior vice president of the American Telemedicine Association, has called this the “Telehealth Super Bowl,” and he’s hoping for a win, even as the contest moves late into the fourth quarter.

“The extensions in this proposed legislation are very meaningful for countless Americans and would give our healthcare providers and hospital systems some certainty and the confidence needed to continue to invest in needed telehealth services,” Zebley said in a statement.

“This has been years in the making, and we must ensure that these extensions are kept intact as they go to vote in both chambers of Congress and then on to President Biden for signature.”

The measure included language to enable health systems to provide cardiopulmonary rehabilitation services via telehealth to Medicare beneficiaries in their home in 2025 and 2026. The package also included a five-year extension of the Medicare Diabetes Prevention Program Expanded Model through 2030, allowing services to be delivered virtually.

Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, said the group is “pleased that Congress heeded our call to extend telehealth flexibilities through the end of 2026.” But the group said it’s frustrated that Congress hasn’t averted planned Medicare payment cuts to physicians.

Healthcare providers and trade groups have long expressed optimism that Congress and the Biden administration would ultimately sign off on an extension of telehealth programs. The House & Energy Commerce Committee passed the 

 unanimously with a 41-0 vote in September.

Republicans and Democrats in Congress have both expressed strong support for telehealth programs. But healthcare advocacy groups expected that Congress 

would likely deal with telehealth extensions in end-of-year spending bills

, particularly with lawmakers spending so much time on the election in the fall. With the end of the year drawing closer, telehealth supporters have been sweating a bit.

Zebley is hopeful that providers won’t have to worry about virtual care programs being disrupted.

“This is shaping up to be a historic week for advancing telehealth and puts us on a path towards a modernized healthcare system,” Zebley said in a statement.

Health systems have expressed cautious optimism about a five-year extension of hospital-at-home programs. Nationwide, 378 hospitals in 39 states are providing acute care at home, according to 

 from the Centers for Medicare & Medicaid Services.

More providers are offering hospital-at-home programs

, but some have been wary of launching such services until they get more certainty about the prospect of long-term reimbursements.

Last month, the federal government approved an extension for 

providers to continue remote prescriptions

 of certain controlled substances, such as Oxycontin and Xanax, through 2025.

Lawmakers added measures to extend telehealth and hospital-at-health programs to a bill to avoid a government shutdown. But the spending plan fell apart.

Topic

Telehealth extensions have support in Congress, but spending deal collapses

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Mehmet Oz, MD, has been one of America’s most famous doctors for years, and now he’s poised to take oversight of the Medicare and Medicaid programs.

President-elect Donald Trump announced Tuesday that he has nominated Oz to lead the Centers for Medicare & Medicaid Services. It’s the latest in a series of unconventional cabinet picks for Trump, including his nomination of Robert F. Kennedy Jr. to lead the U.S. Department of Health & Human Services.

 his pick, Trump touted the prospect of Oz and Kennedy working together to lead the nation’s health policy. The health department includes the CMS.

“Dr. Oz will work closely with Robert F. Kennedy Jr. to take on the illness industrial complex, and all the horrible chronic diseases left in its wake,” Trump said.

Concerns mount over prospect of Robert F. Kennedy Jr. leading HHS

A cardiothoracic surgeon who once led the heart institute at New York Presbyterian Medical Center, Oz gained fame through frequent appearances on Oprah Winfrey’s talk show. He later had his own show which ran for 13 years. He stepped away from the show to run for the U.S. Senate in 2022, and he lost to current U.S. Sen. John Fetterman, D-Pa.

“Our broken Healthcare system harms everyday Americans, and crushes our country’s budget,” Trump said in his announcement. “Dr. Oz will be a leader in disease prevention, so we get the best results in the world for every dollar we spend on healthcare in our Great Country. He will also cut waste in fraud within our country’s most expensive Government Agency.”

Like some of Trump’s other choices for top Cabinet posts, including Kennedy, Oz brings no experience running a large, government organization.

 on X, Oz said he welcomed the opportunity.

“I am honored to be nominated by @realDonaldTrump to lead CMS. I look forward to serving my country to Make America Healthy Again under the leadership of HHS Secretary @RobertKennedyJr.,” Oz wrote.

 on X that he is “very excited” by the choice of Oz and thanked Trump for an “outstanding nomination.”

“Welcome Dr​. Oz to ​The Avengers,” Kennedy wrote.

The CMS’s programs touch the lives of 160 million people, or roughly 1 in 2 Americans, through Medicare, Medicaid, the Children’s Health Insurance Program and the Marketplaces.

The head of the CMS requires Senate confirmation, and with a relatively narrow margin in the Senate, Oz would need to hold onto the support of all Republican senators if most Democrats vote against the pick. Republicans are slated to hold a 53-47 majority in the Senate.

U.S. Sen. Elizabeth Warren, D-Mass., offered a 

“Running Medicare and Medicaid for over 100 million Americans isn't like hosting a daytime talk show,” Warren wrote. “Dr. Oz is another rich guy who doesn't care if your health care costs go up or an insurance company denies you coverage. These decisions have life and death consequences.”

Rep. Frank Pallone, a New Jersey Democrat, assailed the nomination of Oz.

“Given the crucial importance of this agency, I am alarmed that President-elect Trump has chosen a TV celebrity without the experience or background to lead it,” Pallone said in a statement Tuesday. “Unfortunately, this nomination further demonstrates that Trump is not concerned about Americans’ health care.”

“By nominating both RFK, Jr. and Dr. Oz, Trump is doubling down on leaders that peddle in dangerous misinformation that endangers public health,” Pallone said.

U.S. Sen. Bill Cassidy, R-La., is a physician and he offered a statement of support for Oz. Cassidy will serve as chairman of the Senate Health, Education, Labor and Pensions Committee next year.

“It has been over a decade since a physician has been at the helm of CMS, and I look forward to discussing his priorities,” Cassidy 

 on X. “This is a great opportunity to help patients and implement conservative health reforms.”

An interesting vote to watch in the Senate could involve David McCormick, the Republican Senate nominee from Pennsylvania. The Associated Press and other outlets have called McCormick the victor in his race against longtime U.S. Sen. Bob Casey Jr., D-Pa., but Casey has not conceded and 

. McCormick narrowly lost to Oz in the 2022 Senate Republican primary.

Oz may be able to count a vote from Sen. Fetterman, 

Fetterman told CNN that he could support Oz if he makes a commitment to preserve Medicare and Medicaid, and he reiterated that in a 

“If Dr. Oz is about protecting and preserving Medicare and Medicaid, I’m voting for the dude,” Fetterman wrote.

Oz brings credentials as a physician to the post, unlike Kennedy, who doesn’t have a medical or scientific background. 

Healthcare leaders have denounced Trump’s choice of Kennedy

 to lead the health department, citing his vaccine skepticism and lack of experience in health or science.

Still, Oz received plenty of scrutiny during his years hosting his television show. Critics bashed Oz for pushing what he touted as miracle cures for weight loss on his show. In 

, researchers found “believable evidence” for only a third of the recommendations on “The Dr. Oz Show.”

Jonathan Reiner, MD, a professor of medicine at the George Washington University School of Medicine & Health Sciences, notes Trump’s choice of Oz is “another odd appointment.”

“True, Oz is a doctor, but the CMS post is something more suited for a policy wonk,” Reiner 

 on X. “Before assuming her post, the current administrator, Chiquita Brooks-LaSure was deputy director for policy at the Center for Consumer Information and Insurance Oversight within CMS, and earlier at HHS as director of coverage policy.”

Annie Andrews, MD, who ran for Congress in 2022, assailed the Oz nomination on the heels of Trump’s choice of Kennedy to lead the health department.

“If you asked any doctor, any reasonable doctor in this country, who, like, the worst two people for these jobs would be, these would be two people on the top of the list,” Andrews said in a video she posted to X.

Andrews said cuts to Medicare or Medicaid payments to doctors and hospitals would potentially disrupt healthcare.

“Our healthcare system is built around the existence of the Medicaid and Medicare programs. Doctors, offices and hospitals rely on funding from these two programs to keep their doors open,” Andrews said.

Hospitals and physicians have both bemoaned Medicare reimbursements. Hospitals have said 

Medicare and Medicaid don’t offer sufficient reimbursements

Doctors and their trade groups have assailed CMS for continually cutting reimbursements to doctors, saying the cuts threaten access to care and could spur some doctors to opt against seeing Medicare patients. Physicians and hospitals have called on CMS and Congress to come up with a better payment structure for doctors.

Medicare 2025 payment cuts to doctors are finalized, and physicians are fuming

Trump has said he has no plans to cut Medicare, and some analysts have expressed doubts that he will impose cuts to beneficiaries.

Seema Verma served as administrator of the Centers for Medicare & Medicaid Services during the Trump administration. 

 last month that she didn’t foresee Medicare cuts under Trump, saying, “He’s very protective of the program.”

When it comes to Medicaid, Verma said Trump would definitely give more deference to the states regarding Medicare, and he’d be focused on seeing money go to those in need.

The famed heart surgeon, television host and former Senate candidate would oversee the huge agency. Trump said he’d be a good partner to Robert F. Kennedy Jr., the HHS nominee.

From TV to CMS? Trump picks Dr. Oz to run Medicare and Medicaid, and some aren’t applauding.

Bea Grause is striving to help everyone understand the gravity of the problems facing the healthcare industry.

The president of the Healthcare Association of New York State, Grause has been talking to healthcare leaders about the difficulties which only stand to become more daunting in the future. But she’s also talking to leaders beyond the world of healthcare.

In an interview with Chief Healthcare Executive®, Grause outlines her efforts to educate leaders from all sectors and galvanize support for developing solutions to ensure patients have access to the care they need.

“It is about supply and demand,” she says. “We have an aging population. It's not just the aging population, but that's a big driver. As we have increasing and changing demand, we're also faced with a chronic national workforce shortage.”

Earlier this year, the hospital association released a 

, “The Case for Change,” outlining some of the headwinds facing health systems. More patients are having trouble getting access to the care they need, the shortage of workers could worsen over time, and many can’t afford the costs of healthcare.

“We have been using it all year to talk to other leaders, to try to level set and get everyone on the same page around what are some of the big drivers, what's happening in healthcare, that has everyone so concerned,” Grause says.

“This document is step one. It's about, how do we get everyone to get and everyone to really look and understand the underlying challenges that are causing our healthcare system to begin to fail,” she explains.

(See part of our conversation in this video. The story continues below.)

Bea Grause is reaching out to leaders to address the challenges in the healthcare industry.

Healthcare Association of New York leader aims to galvanize change

Hospitals in New York continue to face formidable financial challenges

. Three out of four New York hospitals (74%) say they don’t have sufficient margins enabling their organizations to invest properly in patient care, according to a survey by the state’s hospital trade groups released in late November.

Half of New York’s hospitals have negative operating margins, according to the survey.

In addition, New York’s hospitals project that the statewide median operating margin for 2024 will be 0.0%. Revenues are improving for some hospitals, but they aren’t keeping pace with higher costs.

The combination of higher expenses and modest revenue improvement “continues to create a financially fragile healthcare system in New York,” Grause says.

The healthcare challenges in New York state are very connected, Grause says. More patients are having trouble accessing primary care, so they often are showing up in hospital emergency departments.

More New York hospitals are boarding patients for longer periods in emergency departments, reflecting 

a serious problem affecting hospitals nationwide

. In New York, as in other states, many patients are stuck in the emergency department because there aren’t inpatient beds available, either due to staffing shortages or a lack of beds at nursing homes and other post-acute care facilities, Grause says.

The lack of nursing home beds is creating added strain on New York hospitals.

“We have 7,000 fewer nursing home beds today in New York state than we did in 2018,” Grause says.

The shortage has been especially problematic in Rochester, which has seen significant boarding of patients in emergency departments, while some hospital patients could be discharged but are still waiting to be placed in nursing homes, she adds.

In addition to causing financial strain for hospitals by limiting their ability to treat more patients, and boarding others for longer periods, patients are suffering as well.

“It hurts patients in terms of them being able to get the care they need,” Grause says.

And that’s why Grause is urging policymakers and business leaders to see that there’s a need to address the workforce challenges affecting all levels of healthcare, including primary care, hospitals, and post-acute care.

“That supply and demand challenge is not going to be a blip on the screen. It is going to be over the next 25 years,” Grause says.

Fundamentally, the healthcare industry is facing rising demand for services, especially as the last of the Baby Boom generation approaches retirement age at the end of the decade. And Grause notes many doctors and nurses are in their 50s and may be approaching retirement as a growing wave of older Americans have more needs from the healthcare system.

Many hospitals continue to struggle to hire and keep enough nurses, and that’s a problem at many New York hospitals as well, Grause says. It’s one that is especially meaningful for her as a registered nurse who previously worked in the emergency department.

But as Grause says, hospitals are struggling to fill a number of positions.

“There's a lot of competition, particularly as if you are thinking about certified nurses’ assistants, LPNs or other technical positions,” she says. “There's competition for those entry level positions in other industries.”

While staffing shortages are a statewide problem, rural hospitals are having significant difficulty in filling positions, she says.

Grause says it’s time to think more creatively about recruiting people at earlier ages, including high school and even middle school, to develop an interest for careers in the healthcare industry.

That’s why Grause says she has been reaching out “beyond our traditional partners.” Grause says she has been talking to leaders in other businesses, union groups, and teachers unions “about ways that we can work together on workforce priorities.”

With the costs of healthcare out of reach for many patients, Grause also says she’s trying to help gain support for policymakers to tackle affordability. Actually, she calls it “the paralysis of unaffordability.”

In more than 30 years of health policy, leaders have been talking about reducing healthcare costs.

Grause suggests reframing the question, asking, “How do we meet increasing and changing demand in ways that produce affordability over time?”

She also sees more potential to treat patients outside the four walls of the hospital, including hospital-at-home programs. And she says she’s hopeful that artificial intelligence can help health systems operate more efficiently and improve the delivery of care to patients.

“We have to think about ways that we are going to continue to deliver high quality care in ways that meet consumer demand, but actually are more efficient and effective for the population we serve,” Grause says.

Despite the problems facing New York hospitals, Grause maintains a sense of confidence that solutions can be found.

“It's going to require strategic and bipartisan approaches,” she says.

She also says it’s going to take time, but she’s aiming to rally policymakers around the problem.

“There's no cheap, easy or quick solutions to any of this,” Grause says.

“It's going to take a lot of years to figure out how we address these drivers,” she adds. “But until we agree on the problem, we're never going to get there.”

Taking a proactive approach to reducing violence in healthcare

Bea Grause talks about the struggles of New York hospitals and the need for a comprehensive approach to alleviate staff shortages and ensure access to healthcare.

Healthcare Association of New York State leader makes the case for change

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Lindsay Burrows

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