Monday, July 20, 2026

New analysis shows private Medicare Advantage plans are denying rehabilitation care at alarming rates. The denials target skilled nursing facility stays, inpatient rehab, and home health services post-hospitalization, often citing lack of medical necessity. This creates immediate cash flow pressure for rehab providers and hospitals. Practices must preemptively strengthen clinical documentation for rehab orders, specifically linking functional status to the prescribed level of care. Consider concurrent review for any MA patient transferring to post-acute care, as denials are issued retroactively. Appeal promptly with physician narratives that detail daily skilled needs.

A second Colorado family reports a NICU claim denial due to confusion over the "birthday rule" for newborn coverage. The rule determines which parent's insurance is primary for a newborn based on the parents' birth dates, but families and providers often misapply it, leading to coverage gaps and denials for expensive neonatal care. This is not an isolated payer policy but a systemic coordination-of-benefits failure. Practices should update newborn registration protocols to explicitly ask for both parents' insurance details and birth dates at admission. Verify primary coverage with both payers before billing, not after. Monitor for similar denials in pediatrics and OB/GYN; incorrect COB assignments trigger recoupments.

CMS published draft guidance for the second year of the Inflation Reduction Act's Medicare Drug Price Negotiation Program, setting the stage for 2027 selections. The agency is requesting public comment on the negotiation framework, including methodologies for selecting drugs and determining maximum fair prices. Drugs subject to negotiation for the 2027 cycle will be announced later this year, with negotiated prices set to take effect in 2028. The draft guidance and comment period indicate ongoing implementation of the program's controversial price-control provisions, which will impact Part D and Part B drug reimbursement. Practices should monitor the comment period for potential impacts on specialty drug access and reimbursement for 2027.