News to Note – November 2026

• As of October 1st, we are officially in fiscal year 2027, which means all the hard work you did to reduce your hospital’s length of stay and increase the case mix index over the last year has gone out the window.
• Why? October 1st is when the Centers for Medicare and Medicaid Services (CMS) resets all the Diagnosis-Related Groups (DRG) weights and the geometric mean length of stay (GMLOS).
• Because hospitals are continually working to shorten length of stay and reduce costs, the data CMS uses to reset the values each year reflects shorter patient stays and lower costs. Sometimes you just can’t win.
• We’re also in open enrollment season when beneficiaries can switch their Medicare plans. They can go from traditional Medicare to Medicare Advantage (MA), switch from one MA plan to another, or give up their MA plan entirely and go back to traditional Medicare. But if they switch from MA back to traditional Medicare, they may not be able to obtain a supplement plan.
• Because the open enrollment process is complex, many Medicare beneficiaries use insurance brokers to help them pick a plan. The Center for Medicare Advocacy issued a recent warning that there are increasing reports of these brokers aggressively cross-selling other insurance products. The Center advises beneficiaries to ask questions and avoid falling for high-pressure sales tactics. 
• The Center also reports an increasing number of cases involving beneficiaries with MA plans who reside in nursing facilities. In these cases, the facility disenrolls the beneficiary from the MA plan without their knowledge or consent. This isn’t new news – CMS first reported on this in 2015. While the reasons are not entirely clear, one possibility involves facilities wanting to return patients to Medicare Part A and Part B. This would allow the facility to provide covered care like therapy services, without having to obtain MA authorization and submit clinical notes every few days to extend that authorization.
• What is “site neutrality?” Payers want it so they don’t have to pay a hospital more for performing a surgery when it could have been done at an ambulatory surgery center (ASC) or physician’s office. So far, there has only been talk in Washington about this. But one payer, Elevance Health, has come up with a workaround to reduce some of its expenditures. It is going to start requiring that claims for services at hospital-owned facilities include the address where the service was provided rather than just the hospital’s billing address. This will allow Elevance Health to adjust payments for services performed off-campus to the same rate they would pay an independent facility unaffiliated with a hospital or health system.
• October 1st marked the loss of Medicaid coverage for hundreds of thousands of immigrants who are lawfully present in the country but do not have permanent resident status. This adds to the estimated 760,000 people who were disenrolled from their Marketplace plans by CMS a couple of weeks ago. Many of these people will end up in our hospitals needing medical care and once again it will fall upon hospital case managers to develop safe and effective plans for their care.
• Price transparency is in the news again after another overhaul of the rules from the Department of Health and Human Services (HHS). Most of us have been somewhat removed from price transparency regulations, with finance in charge of posting prices for public use and providing patients with estimates. But how long that will last is unclear. When we offer patients a choice of post-acute providers, will the government eventually require us to provide charges for each facility so patients can choose based on cost? How can we give an accurate estimate of the cost of a hospital stay? How can we know how many EKGs or CT scans the patient will need or how many consultants will be called? Perhaps HHS could provide patients with better information if it required more discrete data on the quality of care.
• The fifth update to the definitions of acute myocardial infarction has been released and is sure to create confusion among clinicians, Clinical Documentation Integrity Specialists (CDISs), and coding staff. Many of you likely remember the big push to get doctors to document Type 2 MI when the troponin rises but there is no coronary artery blockage. Now there is no longer a Type 2 MI; instead, it’s called a “secondary myocardial infarction.” Read the updated definitions to bring yourself up to speed so you can support your CDI, coding, and medical staff.
• A recent bulletin from Blue Cross of Michigan applies to all its Medicare Advantage products in the state. 
• The memo starts by explaining the important role of discharge planning when patients are hospitalized and notes, “discharge planning should begin early in the hospitalization and be reassessed as the patient’s needs change.” But then they state, “providers submitting an authorization request for an acute inpatient medical and surgical admission for a member will be required to include the member’s discharge planning evaluation along with the clinical information required for the request.” They go on to describe the elements of a discharge planning evaluation including an anticipated discharge disposition and date, the patient’s clinical needs at discharge, the patient’s functional and social needs, and the availability of post-acute care services for the patient.
• It’s unclear what Blue Cross of Michigan understands about case managers and discharge planning. They aren’t lined up in the Emergency Department waiting for new patients to start developing a discharge plan before there is even a diagnosis or treatment plan. Do they expect the case manager to call the family to talk about discharge plans for their critically ill loved one even before it’s known if they’ll survive their acute illness, just so the hospital can notify Blue Cross of the inpatient admission?
• They also have a statement in another policy that says, “When an admission occurs through the emergency room, Blue Cross Network asks that the facility contact the primary care provider prior to admission to discuss the member’s medical condition and to coordinate care prior to admitting.” It’s not clear who in “the facility” is supposed to call the primary care provider’s office, sit on hold for a while, and then discuss their patient’s post-acute needs while the patient is in the ED following a major trauma or cardiac arrest, but Blue Cross says someone has to talk to the primary care doctor first before hospitalizing the patient as an Inpatient.
• CMS’s Rural Health Transformation (RHT) Program, a $50 billion, five-year initiative intended to strengthen healthcare delivery across rural America, provides $10 billion annually from fiscal years 2026 through 2030. The funding is directed toward improving access, strengthening the rural healthcare workforce, supporting innovative care models, and advancing technology.
• Earlier this year, much of the discussion centered on whether the RHT Program could meaningfully offset the broader financial pressures facing rural hospitals and health systems. It remains important to recognize that short-term transformation funding cannot directly address ongoing reimbursement concerns in our states.
• This new initiative seeks to shift Medicaid’s quality strategy toward outcomes, rather than continuing to expand reporting requirements for states, health plans, and providers. CMS has invited states and other stakeholders to sign a voluntary pledge focused on four principles: prioritizing outcomes over process, consolidating quality-measure inventories, producing more real-time data when feasible, rather than relying on claims and chart abstractions, and ensuring that payment incentives align with outcome metrics. As of Sept. 24, 37 states have signed the pledge, representing approximately 56 million Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries.
• The RHT Program calls for evidence-based, measurable interventions related to disease prevention, chronic disease management, behavioral health, prenatal care, workforce development, technology, access, and innovative care delivery. It also supports value-based arrangements intended to improve quality, reduce costs, and shift care into lower-cost settings.
• These developments offer an opportunity to reduce unnecessary reporting, particularly around process metrics, and focus attention on measures that more directly reflect whether people are healthier because of the care they receive. Although there are concerns that success will depend on whether rural organizations actually have the infrastructure necessary to demonstrate and sustain those results, aligning metrics and shifting the focus towards health improvement represents a step in the right direction.
• The National Uniform Billing Committee (NUBC) is considering the creation of two condition codes, one for when a patient chooses a less-than-optimal location for discharge and another for when the payer refuses to approve the suggested post-acute care. The committee has yet to analyze the implications of these potential new codes for other parts of the claim preparation and payment rules.
• For now, make sure your clinicians document when a patient with complex rehabilitation needs can’t go to Inpatient rehabilitation because their payer won’t approve it, or when a patient needing daily skilled nursing care in a SNF insists on going home. As previously suggested, these discharges can also be reasonably identified as Against Medical Advice (AMA) discharges.
• If you want to support this effort, you can email the NUBC at [email protected] and tell them your hospital routinely has these suboptimal and high-risk discharges and would welcome a way to designate them as such. Hearing from case managers and others who face these discharges regularly may help convince the committee that the codes are warranted.