White House reaches first Most-Favored-Nation pricing deal, realigning U.S. drug costs to international benchmarks and reshaping payer and provider reimbursement strategies.
CMS finalizes 2028 Medicare Drug Price Negotiation guidance, expanding orphan drug protections, integrating Medicare Advantage data, and clarifying vaccine treatment.
URAC has unveiled the country’s inaugural Health Care AI Accreditation program, an independent framework that evaluates artificial-intelligence solutions for safety, equity, transparency, and measurable clinical impact. The new credential offers payers and providers a concrete way to vet AI tools, align with emerging regulatory guidance, and advance value-based care objectives while mitigating compliance and reputational risk.
CMS has released new guidance tightening federal oversight of Medicaid state-directed payments (SDPs) in managed care. The update centers on transparency, documentation, and measurable quality outcomes—signaling stronger guardrails on financing, distribution methodologies, and alignment with actuarial soundness and value-based care. Payers, providers, and state agencies should prepare for enhanced monitoring and reporting expectations.
HHS has finalized a rule (HTI-4) to deliver real-time prescription drug price transparency at the point of care, giving clinicians and consumers visibility into patient-specific coverage, out-of-pocket costs, and prior authorization requirements through certified health IT. The move aims to reduce administrative burden, speed access to therapy, and support more cost-effective prescribing aligned with value-based care goals.
HHS and CMS are creating the Healthcare Advisory Committee, a group of experts tasked with providing strategic recommendations directly to HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Dr. Mehmet Oz.
The goal: improve how care is financed and delivered across Medicare, Medicaid, CHIP, and the Health Insurance Marketplace, while reducing red tape and putting patients first.
The Centers for Medicare & Medicaid Services’ (CMS) WISeR model (originally designed to streamline utilization management and prior authorization processes) is facing renewed attention from lawmakers. A bipartisan congressional letter sent to CMS questions the agency’s legal authority to apply the model to traditional Medicare and warns of potential impacts on beneficiary access, provider operations, and program compliance. As the healthcare industry awaits CMS’ response, payer and provider organizations should prepare for possible policy adjustments that could affect authorization workflows, clinical operations, and financial performance.
The U.S. Department of Health and Human Services (HHS) has finalized pivotal regulations designed to streamline e-prescribing and prior authorization processes. These new rules aim to enhance interoperability, reduce administrative burdens on healthcare providers, and improve patient care outcomes. As the healthcare landscape shifts towards value-based care, it is essential for decision-makers in healthcare organizations to align their systems with these changes to ensure compliance and optimize operational efficiency.
White House & CMS partner with 60+ healthcare and tech leaders to launch a patient‑centric digital health ecosystem with interoperability at its core.
The Trump Administration’s America’s AI Action Plan outlines a strategic framework for integrating artificial intelligence into healthcare, addressing both the opportunities and challenges it presents. By fostering collaboration among stakeholders and establishing regulatory guidelines, the plan aims to enhance patient care, ensure compliance, and drive innovation. This Industry Watch Alert highlights the key implications of the AI Action Plan for healthcare payers and providers, emphasizing the need to align AI advancements with value-based care initiatives.
