Tuesday, September 8, 2026

CMS announced a town hall meeting for manufacturers and applicants seeking new technology add-on payments for Fiscal Year 2028. These payments provide extra reimbursement for costly, breakthrough medical technologies used in inpatient settings. The agency will review applications for technologies that are new, represent a substantial clinical improvement, and are not adequately paid under existing DRGs. The meeting signals CMS's 2028 payment rule development cycle is starting. Monitor CMS-2026-18226 for the meeting date and submission deadlines. Practices using or considering new implantable devices, diagnostic tests, or surgical technologies in the hospital should track this process; approved NTAPs can significantly impact hospital DRG payments and supplier contracts for the tech.

North Carolina's Medicaid program and the State Health Plan for teachers and employees are taking opposing approaches to coverage of GLP-1 drugs for weight loss. The State Health Plan is restricting coverage, while Medicaid continues to cover the medications under certain criteria. This creates a coverage chasm for patients based solely on their insurance type, complicating prescribing and prior authorization workflows for practices serving both populations. The divergence reflects a broader national split as payers grapple with the high cost of these drugs. For billing teams, this means maintaining separate knowledge bases for payer-specific GLP-1 policies and preparing for potential appeals when coverage is denied for state employees but approved for Medicaid patients with similar clinical profiles.

A new analysis shows employer-sponsored insurance plans in Virginia paid doctors 28 percent more than Medicaid managed care plans for the same preventive office visit. The payment gap highlights the persistent reimbursement disparity between commercial and government payers for identical services. For practices with a mixed payer portfolio, this reinforces the financial impact of payer mix on revenue. The data provides concrete evidence for contract negotiations with commercial payers and underscores the operational necessity of accurate payer-specific fee schedule management. While not a new trend, the quantified gap offers a benchmark for Virginia practices assessing their own reimbursement rates against market averages.

A rural Iowa pharmacy owner directly appealed to U.S. Senate candidate Josh Turek, stating that federal intervention is required for independent pharmacies to survive. The plea highlights the ongoing financial strain on rural providers from low reimbursement rates, particularly from Medicaid and Medicare Part D, and from pharmacy benefit manager practices. This is a live signal of the mounting pressure on Congress to address rural pharmacy closures, which directly impacts patient access to medications and local economies. For practices, the continued erosion of the rural pharmacy network means longer patient travel for prescriptions and potential disruptions in medication adherence.