Friday, May 29, 2026

CMS finalized changes to the No Surprises Act independent dispute resolution process on May 28, 2026. The new rule aims to reduce administrative burden and speed up arbitration decisions for out-of-network charges. This follows complaints that the original process was slow and unpredictable, leaving providers with long payment delays. The overhaul clarifies documentation requirements, streamlines timelines, and adjusts the qualified payment amount methodology. Billing teams should review the final rule's procedural changes now, as new requirements for initiating and supporting IDR claims are likely effective within 60 days. Expect payer portals to reflect new submission protocols by Q3 2026.

CVS Caremark announced on May 28, 2026, that Eli Lilly's GLP-1 obesity medications Zepbound (tirzepatide) and oral Foundayo (orforglipron) will be added to its formulary. This reverses a previous exclusion and significantly expands patient access. The decision impacts commercial plans administered by CVS Caremark, including many Aetna and Cigna employer plans. Billing teams should prepare for an increase in prior authorization and medical necessity review requests for these agents. Monitor plan-specific bulletins for coverage criteria and step-therapy requirements. The move also pressures other PBMs to follow suit, potentially shifting the broader payer coverage landscape for weight management drugs in late 2026.

HHS, Labor, and Treasury issued a final rule reforming the independent dispute resolution process under the No Surprises Act. The rule aims to reduce administrative burdens for payers and providers and stabilize the arbitration system following early operational struggles. Changes include revised timelines for payment determinations and adjusted qualification standards for IDR entities. The reforms target a system that saw 60,000 dispute submissions in its first year. Watch for implementation guidance from the agencies; the new procedures will govern all out-of-network payment disputes for services covered under the NSA.

CVS Caremark announced it will return Eli Lilly's injectable GLP-1 weight-loss drug Zepbound to its commercial formularies and add Lilly's new oral agent, Foundayo. The move signals a strategic shift by the PBM following months of restrictive coverage and places Lilly's obesity portfolio on equal footing with Novo Nordisk's Wegovy. The decision affects millions of commercially insured lives and may pressure other PBMs to expand GLP-1 access. Monitor formulary updates from other major PBMs like OptumRx and Express Scripts in the next quarter; this expansion increases the likelihood of patient requests for these high-cost therapies.

A May 29, 2026, analysis reports that small and rural hospitals are falling behind in AI adoption for revenue cycle management, creating a widening operational gap with larger health systems. The market split is driven by the high cost of implementation and a lack of specialized IT staff. This disparity leads to slower claim processing, higher denial rates, and reduced coding accuracy at smaller facilities. While not a policy change, the trend signals a growing competitive disadvantage. Independent practices should evaluate their own RCM technology against evolving industry standards to avoid similar inefficiencies as payer AI tools become more sophisticated.