Saturday, June 27, 2026

CMS published the proposed rule for the End-Stage Renal Disease (ESRD) Prospective Payment System for CY 2027. The agency projects a 1.1% increase in payment rates, translating to a net $100 million rise in Medicare payments. The rule includes refinements to the ESRD Quality Incentive Program, most notably proposing a new measure assessing facility referral for kidney transplant evaluation. This would directly affect nephrology and transplant center referral workflows. The comment period closes August 25, 2026. Dialysis facilities should review the proposed rule's quality measure changes and model the financial impact of the 1.1% base rate adjustment against their current patient mix.

Senate Democrats introduced a bill to establish a $5,000 annual out-of-pocket cap for Medicare beneficiaries. The proposal aims to shield seniors from catastrophic costs as healthcare expenses rise. This follows broader legislative pushes to control patient costs and could reshape financial exposure for high-utilization patient panels. The bill faces an uncertain path in a divided Congress, but its introduction signals a renewed focus on Medicare affordability in the 2026 election cycle. Monitor S.XXXX as it moves through committee in Q3 2026.

A new study provides concrete data on the administrative burden of prescription drug prior authorizations. Researchers measured the time and labor cost incurred by both physician practices and pharmacies to complete a single PA request. The findings quantify a known operational drag, showing that practices spend significant staff hours navigating complex payer requirements for drug coverage. This adds to the evidence base advocates are using to push for PA reform legislation currently moving through Congress. For practice managers, the study underscores the importance of tracking PA-related staff time to accurately represent the cost of this workflow in contract negotiations and operational planning.

CMS issued a formal Request for Information regarding Pharmacy Benefit Manager (PBM) compensation and data collection under Medicare Part D. This stems from the Consolidated Appropriations Act, 2026, which mandates new transparency measures for PBMs operating in the Part D program. The agency is soliciting stakeholder feedback on the types of compensation and cost data that should be reported, how it should be collected, and how it will be used for oversight of plan sponsors. The move signals increased regulatory scrutiny over the often-opaque PBM contracting practices that can impact drug access and costs for Medicare beneficiaries. Part D plan providers and entities contracting with PBMs should monitor this rulemaking for future reporting obligations.

The Texas Supreme Court ruled that the state's decision to continue paying for alleged fraudulent lab tests defeated the 'materiality' element in a False Claims Act suit against LabCorp. The ruling narrows the path for future qui tam cases in the state, establishing that if a government payer knows about alleged misconduct but continues payment, proving material fraud becomes more difficult. This decision could influence enforcement strategies and whistleblower litigation in other states, particularly for lab services and Medicaid billing.