- Administration releases long-awaited No Surprises Act final rule
- New issue briefs on ACA marketplace changes for medical societies and physicians
- Legislation introduced to improve transparency and timeliness in Medicare coverage decisions
- CISA announces new public town hall schedule on CIRCIA rulemaking
- Changes recommended for proposed expanded joint replacement model
- AMA urges CMS to remove EHR and prior authorization burdens
- More articles in this issue
Administration releases long-awaited No Surprises Act final rule
Last week, the Departments of Health and Humans Services, Labor and the Treasury (“the Departments”) issued the Independent Dispute Resolution (IDR) Operations final rule (PDF). The corresponding proposed rule was published in November of 2023 and the AMA, like many other physician groups, submitted detailed comments (PDF) in early 2024.
Broadly, the final rule can be considered positive for physicians and looks to streamline the dispute process and require more information to be provided to physicians. It increases the formality of the open negotiations process and reduces the costs of disputing a claim.
Specifically, and in line with many of the AMA’s previous recommendations, the rule:
Requires plans to use claim adjustment reason codes (CARC) and remittance advice remark codes (RARC), in both paper and electronic remittance advice to assist in clarifying eligibility
Requires more information to be disclosed with the initial payment or notice of denial of payment
Streamlines the efficiency and increases the formality of the Open Negotiation process by requiring that the initiation and response take place via the federal IDR portal
Requires plans and issuers to register in the federal IDR portal so that their information is available to physicians and other parties
Allows for more flexibility in batching items or services into a single dispute, including extending the number of allowed line items from 25 to 50
Reduces the administrative fee from $115 to $15
Shortens the “cooling off period” from 90 to 30 days for batched claims
Unfortunately, the Departments did not fully address the range of concerns identified by many commentors with the 90-day cooling off period. Additionally, the Departments finalized a provision limiting batching to only those claims from the same self-funded payer rather than to all employers using the same third-party administrator. Unfortunately, they also did not extend batching allowances for different levels of evaluation and management services for emergency care.
Many of these new provisions will require further guidance from the Departments, potentially extending their implementation dates for months or even years. For example, guidance on the use of CARCs and RARCs is not expected for six months and with compliance requirements four months after that. Fortunately, the reduced administrative fee takes effect on June 11, and new requirements on information to be shared along with the QPA are effective 60 days after publication (Aug. 3).
The AMA is still analyzing the rule and will be providing more detailed information.
New issue briefs on ACA marketplace changes for medical societies and physicians
The AMA recently published two issue briefs addressing changes to the Affordable Care Act (ACA) marketplaces. The first issue brief (PDF), meant to be a resource for state medical associations and national medical specialty societies, outlines several policy options for states to stabilize their marketplaces and protect patients from reduced access and coverage as a result of the One Big Beautiful Bill Act, the expiration of the advanced premium tax credits, and recent regulatory changes. Such options include safeguards against noncomprehensive health plans, subsidizing premiums, and considering reinsurance programs.
The second issue brief (PDF) is intended for physician use and describes some of the recent ACA marketplace changes, highlights how those changes may impact their patients, and offers suggestions for navigating those changes with patients.
Both of these issue briefs are available on the AMA website alongside a number of other resources addressing recent Medicaid and marketplace reforms. Please feel free to share widely with colleagues, advocates and physicians.
Legislation introduced to improve transparency and timeliness in Medicare coverage decisions
The AMA sent a letter (PDF) to Representatives Neal Dunn, MD (R-FL), Nanette Diaz Barragán (D-CA), and Claudia Tenney (R-NY) in support of H.R. 8500, the Timely Access to Coverage Decisions Act of 2026. The bipartisan legislation would establish enforceable timelines for Medicare Administrative Contractor (MAC) review of Local Coverage Determination (LCD) requests and reconsideration requests, while modernizing the LCD development process to increase transparency and clinical input.
LCDs play a significant role in determining which services Medicare beneficiaries can access in their region. However, the current process for developing, revising, and challenging LCDs is often opaque, inconsistent across contractors, and subject to lengthy delays. As a result, physicians and patients can wait years for decisions regarding Medicare coverage, creating uncertainty and potentially limiting access to evidence-based care.
H.R. 8500 would address these concerns by requiring MACs to determine within 60 days whether an LCD or reconsideration request is complete and to issue a final decision within one year of receiving a complete request. The legislation would also require draft determinations to be publicly available, establish open public meetings, incorporate expert clinical input from practicing physicians and Contractor Advisory Committee members, and provide a public comment period of at least 30 days. In addition, final coverage determinations would be required to rely on defined categories of qualifying evidence, including peer-reviewed research, systematic reviews, evidence-based consensus statements, and clinical guidelines.
The AMA also highlighted the bill’s provision allowing the Secretary of Health and Human Services to review a MAC’s final reconsideration decision at the request of an interested party. This additional layer of oversight would help ensure that coverage determinations are clinically grounded, consistent with Medicare policy, and based on an appropriate interpretation of the available evidence.
The AMA applauded Reps. Dunn, Barragán, and Tenney for introducing the legislation and reaffirmed its commitment to working with Congress to create a more transparent, predictable, and patient-centered Medicare coverage determination process.
CISA announces new public town hall schedule on CIRCIA rulemaking
The Cybersecurity & Infrastructure Security Agency (CISA) released an updated schedule for all critical infrastructure sector stakeholders to participate in town halls on the Cyber Incident Reporting for Critical Infrastructure Act (CIRCIA) Reporting Requirements Proposed Rule. CISA previously scheduled town halls in March and April 2026 that were postponed due to a lapse in government funding for the Department of Homeland Security. The agency is hosting these town halls to allow stakeholders a limited additional opportunity to provide input on refining the scope and burden of the CIRCIA Proposed Rule.
The AMA submitted comments (PDF) on the CIRCIA proposal in July 2024, highlighting that cyber incident reporting is a meaningful component of an entity’s comprehensive cybersecurity plan, while recommending modifications. The comments supported the proposed rule’s criteria that CISA used to determine which entities in a critical infrastructure sector should be covered entities, and agreed that physician practices should not be considered covered entities under this regulation and are not required to report covered cyber incidents or ransom payments. In addition, we urged CISA to explicitly include health insurance companies and intermediaries (e.g., clearinghouses) as covered entities under this regulation, as the February 2024 Change Healthcare cyber incident had clearly demonstrated the interconnectedness of the healthcare ecosystem and the importance of health insurance companies, intermediaries, and clearinghouses in maintaining public health and safety.
The town halls are scheduled for June 15-18, with stakeholders from specific sectors slated to testify on specific days. More information on the town halls and registration information, along with the ability to add your name to the list of potential speakers at the town halls, is available on the CISA website.
Changes recommended for proposed expanded joint replacement model
The 2027 proposed rule for the inpatient hospital payment system includes a proposed nationwide expansion of the Comprehensive Care for Joint Replacement model, called CJR-X. The Centers for Medicare & Medicaid Services (CMS) proposes to implement CJR-X as a mandatory model for most acute care hospitals effective Oct. 1, 2027. Another mandatory CMS model, the Transforming Episode Accountability Model (TEAM), began Jan. 1, 2026, in 190 randomly selected areas and continues for five years. As CJR-X covers the same joint replacement procedures as TEAM, hospitals participating in TEAM will be exempt from CJR-X. The proposed CJR-X episodes include 90 days post-discharge whereas TEAM has a 30-day post-discharge period.
AMA comments (PDF) on CJR-X include recommendations for several important changes from the CMS proposal. Instead of mandating hospital participation, the AMA recommends that participation in CJR-X be voluntary. In addition, physician practices should be permitted to manage CJR-X episodes on a voluntary basis, as they did for 70% of the episodes in a previous CMS bundled payment model.
The AMA is also concerned that the CJR-X proposal does not include any requirement for participating hospitals to ensure that the surgeon has a leadership role in the model. The AMA recommends that CJR-X participating hospitals be required to involve physicians who provide joint replacement surgery at the hospital through the creation of steering committees. CMS should also share data on the CJR-X episodes with these physicians.
Under CJR-X, hospitals that reduce spending on hip and knee surgeries below the target prices set by CMS will share in the savings that are generated for the Medicare program. The proposed rule would allow participating hospitals the option of establishing distribution arrangements with the physicians providing joint replacement procedures at the hospital, but the AMA recommends that such distribution arrangements be required.
The AMA comments also urge CMS to modify its proposal to prevent harm to rural hospitals and patients, as well as patients who have both Medicare and Medicaid coverage and the hospitals that serve them. For example, a key means of lowering episode costs has been reducing post-acute care costs, but rural areas may have higher post-acute care costs that could lead to them being penalized in CJR-X. Dual eligible patients have also had less favorable outcomes in previous models and safety net hospitals with a high proportion of dual eligible patients have not been able to earn shared savings to the same extent as other hospitals. The AMA recommends several modifications to account for these issues and prevent safety net hospitals from being disadvantaged by the model.
AMA urges CMS to remove EHR and prior authorization burdens
The AMA submitted comments (PDF) to CMS on proposed changes to Medicare’s hospital technology reporting program. The AMA supports CMS’ goal of reducing unnecessary reporting burden but urges the agency to avoid policies that would create new costs, new compliance risks or new workflow problems for physicians, hospitals and critical access hospitals.
The AMA’s first priority is making sure electronic prior authorization works in the real world before hospitals are required to rely on it. Physicians have long called for prior authorization to be faster, simpler, and less disruptive to patient care. The AMA supports moving prior authorization into standard electronic workflows and warns CMS not to require hospitals to use certified electronic tools before those tools are widely available, stable and properly deployed. The AMA recommends keeping the current approach for 2027, creating a transition period in 2028, and moving to a fully electronic certified approach only in 2029 or later if the technology is ready.
The AMA is also urging CMS to ensure that reducing federal requirements does not give EHR vendors an opening to remove useful functions, stop maintaining them, or charge extra for features physicians and hospitals already rely on. The AMA conditionally supports removing some outdated certification requirements, but only if CMS and the Office of the National Coordinator (ONC) monitor whether vendors continue to make those functions available, especially for small, rural and critical access hospitals that often have limited negotiating leverage.
The AMA opposes removing safeguards that help ensure Medicare technology reporting is calculated accurately. Physicians and hospitals should not be held responsible for inaccurate scores or payment penalties caused by vendor technology problems they cannot independently verify or fix. If CMS continues to require hospitals to report performance, the technology used to calculate that performance must remain reliable and subject to oversight.
Finally, the AMA urges CMS not to take away existing ways for hospitals to share patient information before newer exchange networks are mature and broadly available. The AMA supports the long-term goal of better information sharing across healthcare, but many hospitals, particularly critical access hospitals, still rely on current exchange options. CMS should keep those options available, or at minimum delay changes, until newer networks are accessible, affordable and supported by clear technical assistance and hardship protections.
