Blog
TEFCA Continues to Scale
TEFCA has entered its next phase. It is operating at volume. It is expanding across the ecosystem. It is scaling as national infrastructure. Participation continues to grow. Exchange activity is increasing. Use cases are broadening. What began as alignment around a Common Agreement is steadily becoming embedded in how health information moves across the country….
From Pilots to Paychecks: Why CMMI’s New Models Matter for Risk Adjustment and Quality
The CMS Innovation Center (CMMI), created by the Affordable Care Act (ACA) in 2010 under Section 1115A, designs, tests, and scales payment and service‑delivery models that improve quality while lowering cost across Medicare, Medicaid, and CHIP, launching 50+ models to date, from ACOs to bundled payments. Recently, they released a flurry of new models, and…
TEFCA Is Maturing — and That’s a Good Thing
TEFCATM was always intended to be a living framework. The latest SOP updates released by the RCE in January 2026 reinforce that vision and represent an important step in TEFCA’s evolution from foundational policy into operational maturity. This round of updates brings needed clarity to how TEFCA is executed-especially around response obligations, IAS participation, and…
From Disruption to Design: Turning Compliance into Competitive Advantage in 2026
Healthcare organizations are facing unprecedented regulatory pressure in 2026 due to a convergence of political, economic, technological, and enforcement forces. Political volatility, driven by election cycles and shifting federal priorities, creates uncertainty as administrations introduce new healthcare agendas, while state-level regulations add complexity for multi-state systems. Heightened public accountability is also fueling stricter mandates, with…
Industry 5.0 and the Rise of Intelligent Risk Adjustment
In the age of Industry 5.0, healthcare is evolving beyond automation and efficiency toward a value-based model that emphasizes human-centric innovation, intelligent collaboration, and strategic data use in population health management. This shift is especially evident in risk adjustment, where the synergy between clinical expertise and advanced technologies like artificial intelligence (AI) and analytics is…
Closing the Loop on Referrals: A Framework for Health System Success
Health systems are losing millions each year to referral leakage, with studies showing up to 65% of referrals leaving the network. Beyond lost revenue, leakage fragments care, erodes quality scores, and frustrates patients and providers. Market and policy pressures make it critical to address this issue now. CFOs demand ROI, clinicians face burnout, and centralized…
Navigating the Financial Fallout
How Providers Can Proactively Prevent Bad Debt and Uncompensated Care Amid H.R. 1’s Medicaid Changes The passage of H.R. 1, also known as the “One Big Beautiful Bill Act,” marks a significant shift in the U.S. healthcare landscape, particularly for Medicaid. With sweeping changes to eligibility, enrollment, and cost-sharing, the legislation is expected to increase…
Proactive Precision: Sharpen the Tools in Your RADV Preparation Toolbox
The Centers for Medicare & Medicaid Services (CMS) recently signaled a dramatic escalation of its efforts to combat fraud, waste, and abuse in Medicare Advantage (MA), and has committed to the sharpening of its tools to accomplish this goal. With the recent announcement that CMS will begin auditing all eligible MA contracts each payment year and…
CMS Provides New Price Transparency Guidance
On May 22nd, 2025, the Centers for Medicare and Medicaid Services issued guidance [1]to support the Executive Order (EO) “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information,” [2] issued February 25, 2025. While the guidance is brief, it centers around the use of average charges, which are used…
Possible Changes to Hospital Price Transparency Requirements
With the February 25th White House issuance of an executive order[1] “Making America Healthy Again by Empowering Patients with Clear, Accurate, and Actionable Healthcare Pricing Information“, we are again faced with new challenges around Price Transparency. The requirements are not detailed but they do give us a few particulars: (a) require the disclosure of the…