“I don’t think a corporation … should be telling people what they can and can’t do,” said the retiree, who suffers from arthritis. "My doctors know me. I know my doctors. and when I'm in pain—which is every morning, waking up to two fists that can barely open—I need something to take care of the pain.”

What’s the role of AI in insurance?

The use of AI in insurance promises that all the rules governing insurance will be followed at a much quicker pace, industry representatives say. V7 Labs, for example, a London-based company that automates document-heavy tasks using AI agents, promises on its website to dispatch tasks that would take 30 to 60 minutes in a traditional claims process to two to three minutes.

Already, 84 percent of the nation’s health insurers are using AI for sensitive processes, like prior authorization for medical care and detecting fraud, the National Association of Insurance Commissioners found in a 2024-25 survey. NAIC is the industry’s standard-setting and support organization.

In 2023, the same organization found that 70% of property insurance companies in the U.S. were using AI or were interested in using it, and 88% of auto insurers were using or planning to use it. How well it can be relied on to interpret the nuances of human needs and evaluate individual circumstances, however, is at the forefront of political debate.

What is the AI law in Florida?

A state bill that would have required all denials to involve a human being garnered bipartisan support in the last legislative session.

“While these tools can improve speed and efficiency, no Floridian should ever have a claim denied based solely on an automated output,” said state Rep. Hillary Cassel, R-Dania Beach, who sponsored the bill that passed the House but failed to advance to the Senate.

The bill, she said, “establishes a clear and reasonable safeguard. It requires that any decision to deny a claim or portion of a claim must be made by a qualified human professional who independently reviews the facts, verifies any AI generated information and documents the basis for that decision.”

Industry representatives lined up against the bill that died. It would also seem to conflict with President Donald Trump’s executive order that no state law should regulate AI. The advancement of AI should not be hamstrung by a “patchwork of 50 different regulatory regimes,” that would put it at a competitive disadvantage with other countries’ AI development, the Dec. 11 executive order says.

Property and auto insurance regulations vary state by state, however, and it’s likely the one area that a case could be made that AI’s application to insurance should be regulated on the state level, said Gabriel Carrillo, program director for the Center for Risk Management and Insurance Education at the University of Central Florida College of Business.

“When you talk about property and casualty insurance, when you talk about life insurance, it’s almost completely regulated at the state level,” Carrillo said.

Does my insurance company use AI?

Industry representatives came before a state House committee to assure lawmakers that AI in insurance has guardrails. Although it’s a machine deciding, those decisions must comply with state rules for settling claims. They also made the case that AI’s speed and efficiency in processing claims could mean lower costs will be passed onto policyholders.

AI’s faster processing will make no difference, according to industry representatives.

“At the end of the day, who is responsible if there is a mistake in the claims-handling process? If it's an AI platform, if it's a human platform, the insurance company is always responsible, and we think that is the consistent piece here,” said Thomas Koval, a retired insurance company executive and current board member of FCCI Insurance Group, a commercial insurer out of Sarasota.

Still, an insurer’s use of AI was among the sticking points that could have meant tens of thousands of Floridians lost access to a hospital network. It was cited as health care giant Tenet Healthcare, which operates five Florida hospitals, went to the last day of its contract with Cigna, another national company, before an agreement was struck.

The contract was inked before deadline, but it was the first time AI has been a matter of contention between a health care entity as big as Tenet and an insurer as large as Cigna. Tenet said the insurance company was denying claims without human review, but Cigna publicly denied it.

Traditional Medicare piloting AI review

A pilot launched in six states this January has raised the alarm on two fronts: Traditional, fee-for-service Medicare enrollees’ procedures will be subject to more prior authorization and that authorization will be done by AI, along with human clinical review, according to federal officials.

The pilot seeks to end the waste in health care that studies have found adds up to about a quarter of the spending in U.S. health care.

Nearly half of the country’s 69.7 million Medicare enrollees get the traditional, fee-for-service public insurance. Traditional Medicare recipients have largely not been subject to denials that enrollees in its more recent evolution, Medicare Advantage plans, have been subject to.

KFF, a national health policy research organization, found that 53 million prior authorization requests were processed by Medicare Advantage plan insurers in 2024, resulting in 4.1 million denials. That compares with traditional Medicare. Their enrollees underwent 625,000 prior authorization reviews in 2024 and 143,705 resulted in denials—a fraction of those conducted through Medicare Advantage plans.

But that could be changing because of the pilot program called the Wasteful and Inappropriate Service Reduction Model (WISeR).

“The WISeR Model helps reduce clinically unsupported care by working with companies experienced in using enhanced technologies to expedite and improve the review process for a pre-selected set of services that are vulnerable to fraud, waste and abuse,” reads the press release from the Centers for Medicare and Medicare.

Evan Saltzman, a Florida State University professor in the Department of Risk Management/Insurance, Real Estate and Legal Studies, sees the pilot as part of an inevitable pull.

“It's moving traditional Medicare toward what's already done in the private sector and Medicare Advantage,” Saltzman said.

But U.S. Rep. Lois Frankel said she’s going to fight against any expansion of the effort, now being tested in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington.

“We believe Medicare was based on a promise that if your doctor says you need care, if you're hurt and you need care, Medicare will be there for you, not AI,” Frankel said.

WASHINGTON, D.C. – Medicare’s coverage and reimbursement policies for chronic kidney disease (CKD), and its most severe form, end-stage renal disease (ESRD), are impeding the delivery of proven, innovative treatment options that can improve patient health, the Ways and Means Health Subcommittee learned at a hearing that examined how to enhance care for kidney patients. 

Medicare spends a disproportionate share on kidney care. At $50 billion annually, the cost of treating patients suffering from ESRD constitutes seven percent of Medicare expenses, yet ESRD patients represent only one percent of Medicare beneficiaries. Kidney care has not had the advancements seen in treating other diseases, in part, due to Medicare’s ESRD payment bundle that encourages consolidation in dialysis care and stifles innovation. To date, Medicare has awarded coverage to just four new ESRD drugs – half of which are no longer widely available – and only one new medical device. Meanwhile, Medicare is not doing nearly enough to encourage proactive treatment interventions that improve patient health and quality of life – including at-home dialysis, early screening tests, and kidney transplants.

For Kidney Patients, Prevention is Often Too Little, Too Late 

In over 50 years since Medicare began covering dialysis services for all ESRD patients, our nation’s health system has failed to adequately catch patients before their kidneys fail – a tragedy worsened by the reality that most cases of ESRD are preventable. Diabetes and hypertension together – both preventable and manageable chronic diseases – account for 75% of new ESRD cases each year. Unfortunately, the Medicare program does not properly emphasize catching the disease early enough to make a difference for patients who need dialysis after it is too late to save their kidney function.

Rep. Vern Buchanan (FL-16): “Dr. Watnick, I was surprised to learn that many cases of CKD and ESRD are preventable chronic diseases. We keep spending more on health care, yet you can make the argument we get sicker as a nation. We must reduce the cost of chronic diseases in terms of that burden in the United States. How do you, when you look at chronic diseases impact kidney health, what can Congress do to support better kidney health care through chronic disease management?”

Dr. Suzanne Watnick, nephrology expert: “There’s a lot we can do. I would start with saying is that we need to start upstream. We want people never to walk through those dialysis treatment doors. How can we make sure, first of all, that we know people even have kidney disease, so making sure that we’re advocating for screening. Nine out of 10 people with kidney diseases aren’t aware that they have it. Anything we can do to ensure that upstream care is recognized is a benefit.”

Home Dialysis Testimonial: “It Allowed Me to Be Able to See My Kids Everyday” 

Only 15 percent of dialysis patients receive treatment at home, even though at-home patients experience faster recovery times, fewer side effects, and higher survival rates compared to traditional dialysis in a center. For rural patients, at-home dialysis can be a literal lifesaver when in-center dialysis may require a multi-hour car trip to the nearest clinic. One witness even went so far as to call in-clinic dialysis for rural Americans “a part-time job that you never signed up for.” In response to Chairman Smith, a preschool teacher shared how receiving dialysis at home, supported by caring health professionals, allows her to continue working. 

Chairman Jason Smith (MO-08): “I am only here in Congress today because a very close family friend once convinced me – a son of an auto-mechanic, and a preacher, and a factory worker from a small town in southeast Missouri – could make a difference in politics. He suffered terribly from ESRD – eventually, the disease took his life. His battle with ESRD is a solemn reminder of the important work this committee and this Congress must do to help Americans struggling with chronic disease. All of us around this room have a personal connection to this disease. I feel strongly a responsibility to follow in his memory, and to the hundreds of thousands of patients suffering from this disease, to take action to ease their pain, improve the care they receive, and, above all, give them hope…Can you talk a little bit about how transitioning from an in-center to an at-home dialysis impacted your quality of life with being able to work and care for your young students?”

Ms. Ashli Littleton, home dialysis patient: “It was a real easy transition, because I had a good support team, from my medical team to my mom at home. I was able to make the transition quite well, and it allowed me to be able to see my kids every day, which is the best part of my day, teaching my little children. It wouldn’t have been possible without the staff that I had with DCI, and their support and encouragement with it, and their trust, that I could do it on my own every day as well.”

Medicare Payment for Dialysis Kills Innovation and Limits Patient Access to Better Treatments

Medicare provides a flat payment, known as the ESRD “payment bundle,” to dialysis providers. The payment’s static nature often precludes dialysis providers from being able to give patients new, innovative drugs because the provider solely bears the cost. Under Medicare’s bundle, all costs end up rolled into a one-size-fits-all payment, with only meager incentives to encourage providers to take up a new or innovative drug. This dynamic prioritizes complacency over innovation in dialysis treatment and has kept care for patients frozen in time as other disease states continue to consistently see advances in research, development, and investment in new and innovative treatments.

Rep. Greg Murphy (NC-03): “Mr. Butler, I think it’s really great for people to understand what this bundle means – that dialysis centers get paid one fee for everything. Will you explain how that has caused problems with being able to really grow innovation, take care of patients better, the fact that you limit this money. I will say this: this is what “Medicare-for-All” looks like…limiting money for a bundle, that’s what “Medicare-for-All” looks like.”

Dr.  John P. Butler, President and CEO, Akebia Therapeutics:“For fee for service patients, a dialysis provider gets roughly $280 for every time the patient sits in the chair, if you will, in the dialysis center. And from that, they have to do the skilled care, drugs, everything comes from that bundle.

“The idea that you bring in a new, innovative product. Our product…treats anemia in patients. It’s based on Nobel Prize winning science. It is highly unique. We just presented data…that showed that if every eligible patient was treated with our product, there’s the potential to save almost $2 billion in hospitalization costs, but that isn’t part of that bundle. The dialysis providers have to decide how to allocate care based on the $280.”

Rep. Murphy: “They get a piece of this pie, and you say you spend it as best as possible. But, if there’s a new drug that’s wonderful and innovative and great, you can’t afford it, you can’t access it.” 

“Disheartening to Hear”: Medicare Incentivizes Expensive Dialysis Over Early Detection

CKD can be detected before progressing into ESRD through tests and evaluating patients who have risk factors like hypertension or diabetes. Medicare can spend less on patients who have their kidney disease detected earlier or on patients who are referred to kidney transplantation – the most reliable and effective treatment for ESRD. Unfortunately, the Medicare payment structure encourages providers to keep patients on dialysis, even though that treatment costs taxpayers significantly more than screening or transplantation. 

Rep. Claudia Tenney (NY-24): “If you could just drill down a little bit from a clinical perspective: what do physicians need to do to more effectively integrate the multiple disciplinary care that we need in order so nephrologists, other primary care, and everybody is managing this patient in advance, before we know that something like this is happening, so that we minimize, or at least, prolong the chance that ESRD is going to occur?”

Dr. Robert Taylor, Chief Medical Officer, DCI: “One of the most important things is identifying the underlying risk factors. Diabetes and hypertension are very common. But making sure that primary care physicians and nephrologists are screening appropriately, checking lab tests, checking urine tests to make sure you’re identifying the patients that are at highest risk. 

“Unfortunately, and I’ll be honest, as a nephrologist, I make a lot more money when someone ends up on dialysis than I do caring for stage four and stage five kidney patients…Advanced kidney disease may cost Medicare [per patient] $35,000, maybe $40,000, a year. When they start dialysis, it jumps up to about $90,000 to $95,000 a year. Unfortunately, the incentives financially, and from a policy perspective, have been set up so that, as a nephrologist, you make more money, and the wheels are greased to put people on dialysis.”

Rep. Tenney: “That’s a disheartening thing to hear.”

Source: https://www.wusf.org/health-news-florida/2026-03-18/changes-organ-donor-status-fall-through-cracks-in-system

President Donald Trump recently signed H.R. 7148, the Consolidated Appropriations Act of 2026. Physicians should be aware of some important provisions in the bill, which are summarized below.

• Medicare telehealth extensions: The bill extends the Medicare telehealth flexibilities that were put into place during the COVID-19 pandemic through the end of 2027. This means that even if another government shutdown takes place between now and the end of 2027, Medicare telehealth flexibilities will remain in place. While a permanent extension would have been preferable, this extension still provides increased certainty for physicians regarding the practice of medicine via telehealth.
  
  
• Medicare Advantage provider directory enhancements: These will require Medicare Advantage plans to do more to ensure that their provider directories are accurate, including through additional reporting provisions. Research has shown that MA plans have inaccurate directories far too often, which calls into question whether they’re consistently meeting their network adequacy standards or effectively engaging in false advertising. These provisions are a step in the right direction.
  
  
• Alternative Payment Model incentives were restored in the bill for the 2026 performance year. This means that physicians who participate in advanced APMs under Medicare rules will continue having the opportunity to earn incentives without penalizing physicians who do not participate in these models.
  
  
• Also included are pharmacy benefit manager reforms, maternal health provisions, and a virtual expansion of the Medicare Diabetes Prevention Program. To learn more about provisions included in the bill, read the American Medical Association’s Feb. 6 National Advocacy Update.
  
  

Medicare Shared Savings Program continues generating savings

The Medicare Shared Savings Program saved $4.1 billion last year, according to the Centers for Medicare & Medicaid Services. The U.S. is now home to 14.3 million patients who are enrolled in ACOs across 511 entities, and analysts have noted that these programs have exhibited continued growth. In short, over the past 12 years, ACOs have gone from being described as amorphous “unicorns” to becoming a ubiquitous part of our healthcare system, with all signs pointing to continued expansion.

Manufacturers that advertise vaccines in Florida that cause injury or harm could be sued under a bill sponsored by Fort Pierce Republican Erin Grall.

Over objections by lobbyists representing organized medicine and business interests, the Senate Committee on Regulated Industries voted, 5-3, Tuesday to pass the proposal, SB 408.

Specifically, the bill would amend Florida law regulating drugs and cosmetics to allow an individual to file a lawsuit within three years following an alleged vaccine-related injury. The bill would provide one-way attorney fees, allowing any claimant who wins to recover “reasonable attorney fees” but not allow winning defendants to do the same.

Traditionally in Florida, one-way fees have been intended to balance the interests of ordinary people against deep-pocketed interests.

The bill defines “advertise” as “a media communication, including, but not limited to, television, radio, print, the Internet, digital or electronic media, product placement, promotion by an influencer in exchange for compensation, or any other manner of paid promotion, that a vaccine manufacturer purchases to promote the manufacturer’s vaccine.”

Discussions between health care providers and their patients or written or promotional materials regarding vaccines, or any promotional materials concerning vaccines displayed in health care facilities, would be specifically exempt from the definition of advertise.

According to a staff analysis of the bill, healthcare and pharmaceutical digital ad spending for 2025 was estimated at $24.8 billion, with traditional ad spending at about $7.9 billion.

Bill sponsor Grall said she thinks the measure would help increase vaccine rates in Florida, which have been plummeting. Statewide, the percentage of fully immunized two-year-olds dropped from about 85% a decade ago to roughly 75%, Grall said.

“Public trust regarding vaccines has diminished. I would argue that increased knowledge of the virtual immunity that manufactures have with regards to vaccine-related injuries has contributed to this declining trust,” Grall told members of the committee Tuesday morning.

“Vaccines have served an important public health service to eradicate disease, and this bill, I believe, is s step in rebuilding public trust of proven vaccines by holding manufacturers accountable.”

Florida Justice Reform Institute President William Large said the bill most likely would run afoul of federal laws that limit vaccine manufacturer liability in certain respects and establish compensation for injuries related to vaccines.

He touched on the National Childhood Vaccine Injury Act of 1986, which established the National Vaccine Injury Compensation Program (VICP), a no-fault program funded by vaccine manufacturers through an excise tax on each vaccine dose. The VICP covers most vaccines routinely given in the United States. Benefits include rehabilitation costs, pain and suffering, attorney fees, and, in the case of death, $250,000.

Another federal law Large referenced is the Public Readiness and Emergency Preparedness Act of 2005 (PREP), which authorizes the Department of Health and Human Services secretary to issue a so-called PREP Act declaration. The declaration allows the government to limit the liability of manufacturers, distributors, health care providers, and others for losses related to the administration or use of vaccines other other countermeasures to blunt any threat.

The PREP law also authorizes HHS to establish the Countermeasure Injury Compensation Program (CICP) to compensate claimants for serious physical injuries and death caused by certain vaccines.

CICP recoveries may include medical expenses, a portion of lost employment income, and a survivor death benefit.

Lastly, there’s the federal Food and Drug Cosmetics Act, which deals with labeling and failure to warn.

Preemption

“Most of this area of law is preempted by three federal acts,” Large said. “I’m also concerned it violates the First Amendment. And it’s also our position it’s bad public policy.”

Health and Human Services Secretary Robert F. Kennedy Jr. has criticized the VICP, calling it “biased” and “corrupt.” Kennedy, who owns a financial stake in a lawsuit against Merck over claims the pharmaceutical company failed to properly warn consumers about risks from its HPV vaccine, Gardasil, has said the protections remove incentives for vaccines to be safe.

Grall’s bill provides that an injured individual may bring an action within three years following accrual of the cause of action. Finally, the bill provides that a court can award a claimant who prevails in an action actual damages, court costs, and reasonable attorney fees.

There’s an identical proposal (HB 339) in the House filed by Rep. Monique Miller, a Republican from Palm Bay.

Committee Chair Sen. Jennifer Bradley, a Fleming Island Republican, thanked Grall for the bill, saying that in the aftermath of the COVID pandemic it’s an important conversation for the Legislature to have.

She said the United States is one of two countries that allow vaccine manufacturers to directly advertise to patients. While she stressed she’s no “anti-vaxer” Bradley said today’s environment is vastly differently than 40 years ago when the federal government agreed to pass the vaccine injury compensation fund in order to help ensure an adequate supply of childhood vaccines.

The environment today, Bradley said, is an “atmosphere of distrust.”

“I think this is an important conversation as we see the rise of a lot of diseases and a lot of cases with an uptick. I think we really need to take a hard look at the public trust we have in these big systems,” she said.

“Is this bill perfect? I don’t think so. Can it get better? Can we talk about it? We can put our head in the sand, but public trust in our health system is weak right now. And I think there are things we can do and conversations we can have to remedy that and to build that back. And I think this is a great first conversation.”

Gov. Ron DeSantis announced more than $20 million in LINE (Linking Industry to Nursing Education) funding to support nursing education, including scholarships, and workforce needs during a press conference at St. Petersburg College's Caruth Health Education Center this week.

Specifically, the funding includes $14.5 million to state colleges and private postsecondary institutions and $6 million to state universities.

"These investments are directly addressing the nationwide nursing shortage by supporting scholarships for nursing students and expanding access to state-of-the-art simulation and instructional equipment," DeSantis wrote.

Under Gov. DeSantis, Florida has awarded $85 million through the LINE program, including $61.5 million to state colleges and private postsecondary institutions, and $24 million to State University System institutions since 2022.

Along with LINE, the state has also awarded $400 million in PIPELINE (Prepping Institutions, Programs, Employers, and Learners through Incentives for Nursing Education) funds to postsecondary institutions, including $240 million for state colleges and districts and $160 million for state universities.

Overall, both initiatives have totaled $485 million since their inception.

"If you look at what we've done in both of these programs, we're now producing a thousand-plus additional nurses than we were before those every year between our state colleges and our state universities," DeSantis said at the press conference. "That's a meaningful increase."

Florida Commissioner of Education Stasi Kamoutsas also praised the new investment for state nurses at the announcement.

"I'm so thankful that this investment is going specifically towards the nursing programs, to be able to beef up those programs to be able to give those students an opportunity not just to see value in themselves, but to give back to their communities," Kamoustas said. "This investment is going to specifically impact 20 of our 28 state colleges, who will receive funding that will reinforce the critical role that our state colleges play as the backbone of our workforce education here in the state," he added.

Effective July 1, 2025, state law requires all Florida-licensed physicians to undergo background screening when applying for initial licensure or renewing their medical licenses.

Because the screening process involves multiple steps, waiting until the last minute to fulfill this requirement is risky — especially if your medical license is due for renewal in January.

Read the FMA’s article explaining what you need to know.

Florida Medicaid Health Care Alert

November 13, 2025

Provider Type(s): ALL

Medicaid Modernization: Start Preparing for New Provider Enrollment System

Source: State of Florida Agency for Health Care Administration

The Florida Agency for Health Care Administration (AHCA) is launching a new provider enrollment system in early 2026 as part of the AHCA Enterprise modernization. This modernization will streamline enrollment, renewal, and account maintenance, making the process faster, easier, and more secure for Medicaid providers.

In preparation, providers should:

• Complete pending enrollments in the current Medicaid Provider Enrollment Application Wizard.
• Review and update account information in the Medicaid Secure Web Portal. If renewal has been triggered, complete renewal there.
• Active Medicaid providers who have not created an account should do so as soon as possible. If you do not have your PIN information, see Password Resets and PINs for support.
• Subscribe to Florida Medicaid Health Care Alerts for updates.

Account Maintenance How-tos:

• Update account information: Account Management – Modify Contact Information.
• Reset password: Visit the Medicaid Secure Web Portal and select “Reset password.”
• Maintain an active account: Log in every 60 days before the password expires.
• Newly enrolled providers will receive a PIN letter within 10 business days. Visit https://public.flmmis.com/public/pinletter/ to activate your account.

Resources:

• Password Resets and PIN Instructions
• Account Maintenance and Reset Password Quick Reference Guide
• Secure Web Portal User Guide

Launching in early 2026, the new Provider Enrollment System will:

• Give providers 24/7 access to their provider account from any device.
• Provide step-by-step instructions so applications are right the first time.
• Make enrollment, renewal, and account maintenance faster and more secure.

What’s Next?

As launch day approaches in early 2026, AHCA will share updates through Florida Medicaid Health Care Alerts, including when new preparation tools become available.

On October 31, 2025, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the 2026 Medicare physician fee schedule (MPFS). 

The AMA submitted detailed comments to CMS regarding its proposals on Sept. 11, 2025.

While the AMA staff analyze and develop a detailed summary of the more than 2,000-page rule, we want to bring a handful of key issues to your immediate attention, in the attached document. 

2026 MPFS Final Rule Topline Summary

“CMS instructed all Medicare Administrative Contractors (MACs) to lift the claims hold and process claims with dates of service of October 1, 2025, and later for certain services impacted by select expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025 (Pub. L. 119-4, Mar. 15, 2025).  This includes claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and Federally Qualified Health Center (FQHC) claims.  This includes telehealth claims that CMS can confirm are definitively for behavioral and mental health services.  CMS has directed all MACs to continue to temporarily hold claims for other telehealth services (i.e. those that CMS cannot confirm are definitively for behavioral and mental health services) and for acute Hospital Care at Home claims. 

Beginning October 1, 2025, for services that are not behavioral health services, many of the statutory limitations on payment for Medicare telehealth services that were, in response to the COVID-19 Public Health Emergency, lifted, and subsequently extended, through legislation again took effect. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on use of the ABN, including ABN forms and form instructions can be found here: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are currently not payable by Medicare in the absence of Congressional action. For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 (Pub. L. 115-123, Feb. 9, 2018), which added section 1899(l) to the Social Security Act, allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restrictions and in the beneficiary’s home. Separate from requirements to participate in the Medicare Shared Savings Program, there is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers to offer these covered telehealth services. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For clinicians in applicable ACOs, telehealth claims that CMS can confirm are definitively for behavioral and mental health services will be paid. At this time, claims for some telehealth services will continue to be held.  For more information, including information on to which ACOs these flexibilities apply: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf (PDF).”

A positive, negative, or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished in 2026. The AMA encourages physicians to review their final score as soon as possible as the deadline to file a Targeted Review is only open until November 14, 2025.

The AMA has sought clarification from CMS and they are still accepting and reviewing Targeted Reviews during the government shutdown. However, some decisions may be delayed due to the need for broader CMS staff review, and some staff are furloughed. There are no plans currently to extend the targeted review period.

For more information, please see the email from CMS below.

Now Available: 2026 MIPS Payment Adjustment Information

The Centers for Medicare & Medicare Services (CMS) has released Merit-based Incentive Payment System (MIPS) payment adjustment information for the 2024 performance period/2026 MIPS payment year.

• Your 2024 MIPS final score determines the MIPS payment adjustment you’ll receive in 2026.
• A positive, negative, or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished in 2026.

 Access Your MIPS Payment Adjustment

• Sign in  to the Quality Payment Program (QPP) website using the same credentials that allowed you to submit your 2024 MIPS data and check your 2024 MIPS final score. Refer to the QPP Access User Guide (ZIP, 4MB)  for more information.
• Click “View Feedback” on the home page and select your organization (Practice, Alternative Payment Model (APM) Entity, Virtual Group).
  • Practice representatives can access individual, subgroup, and group performance feedback (final scores and payment adjustments).
  • APM Entity representatives can access APM Entity-level performance feedback (final scores and payment adjustments).
  • Virtual group representatives can access virtual group-level performance feedback (final scores and payment adjustments).
  • Third party representatives can’t access final feedback or payment adjustment information.

If you don’t have a HARP account or QPP role, please refer to the Register for a HARP Account (re: HARP account) and Connect to an Organization (re: QPP role) documents in the QPP Access User Guide (ZIP, 4MB)  and start the process now.

Medicare Shared Savings Program Accountable Care Organizations (ACOs)

Medicare Shared Savings Program ACOs are encouraged to identify at least one individual within your ACO who can obtain a HARP account with the Security Official role; additional individuals may request the Staff User role. ACO individuals can create and manage their HARP account and QPP access in the ACO Management System (ACO-MS) .

Contact your ACO to find out how you can obtain a HARP account via ACO-MS. If you have any questions, please contact the ACO Information Center at SharedSavingsProgram@cms.hhs.gov  or 1-888-734-6433 (Option 1).

• REMINDER: Representatives of Shared Savings Program ACO Participant Taxpayer Identification Numbers (TINs) and practices with clinicians receiving their APM Entity’s final score won’t be able to access the APM Entity’s performance feedback unless they’ve been granted the “staff user” QPP role for the APM Entity.

Payment Adjustment and Performance Feedback Resources:

• 2026 MIPS Payment Year Payment Adjustment User Guide (PDF, 2MB)  – Reviews information about the calculation and application of MIPS payment adjustments, and answers frequently asked questions.
• 2024 MIPS Performance Feedback FAQs (PDF, 2MB) – Reviews the information available in performance feedback and how to access it. (We’re in the process of updating this resource with the Targeted Review deadline.)
• 2024 MIPS Performance Feedback Supplemental Reports Guide (PDF, 833KB) – Reviews the downloadable supplemental and patient-level reports for administrative claims quality and cost measures.
• 2024 Quality and Cost Benchmarks  – Links to quality and cost measure benchmarks and supporting documentation. (Benchmarks determine measure scores.)

2024 Targeted Review Request Period Open Until November 14, 2025[1]

Beginning with the 2024 performance period/2026 MIPS payment year, the targeted review period closes 30 days following the release of MIPS payment adjustments (refer to 42 CFR 414.1385(a)(2) ).

Who Can Request a Targeted Review?

Individual clinicians, groups, subgroups, virtual groups, APM Entities (including Shared Savings Program ACOs), designated support staff and authorized third party intermediaries may request that CMS review their MIPS final score and MIPS payment adjustment factor through a process called targeted review.

When to Request a Targeted Review

Review your MIPS performance feedback, including your MIPS final score and payment adjustment factor(s), on the Quality Payment Program website . If you believe there’s an error in the calculation of your MIPS final score or MIPS payment adjustment factor, you can request a targeted review now until November 14, 2025, at 8 p.m. ET. Be advised that our ability to respond to inquiries and resolve requests will be delayed in most cases until normal government operations resume.

Examples of circumstances that could prompt a Targeted Review:

• Data were submitted under the wrong TIN or National Provider Identifier (NPI).
• You have Qualifying APM Participant (QP) status and shouldn’t receive a MIPS payment adjustment.
• Performance categories weren’t automatically reweighted even though you qualify for reweighting due to extreme and uncontrollable circumstances.

Note: This isn’t a comprehensive list of circumstances.

How to Request a Targeted Review

To access your MIPS final score, performance feedback and request a targeted review:

• Sign in  using your HARP credentials (ACO-MS credentials for Shared Savings Program ACOs); these are the same credentials that allowed you to submit your 2024 MIPS data and check your 2024 final score.
• Click “Targeted Review” on the left-hand navigation.

CMS may require documentation to support a targeted review request, which varies by circumstance. A CMS representative will contact you about providing any specific documentation required.

• 2024 Targeted Review User Guide (PDF, 2MB)  – Reviews the process for requesting a targeted review and examples for when you would or wouldn’t request a targeted review. (We’re in the process of updating this resource with the Targeted Review deadline.)

[1]  Note: The federal government shutdown doesn’t affect your ability to submit a targeted review request by the above deadline, however it may affect our response time to resolve your request.

Claims Hold Update

In anticipation of possible Congressional action, CMS has instructed all Medicare Administrative Contractors (MACs) to continue to temporarily hold claims with dates of service of October 1, 2025, and later for services impacted by the expired Medicare legislative payment provisions passed under the Full-Year Continuing Appropriations and Extensions Act, 2025. This includes all claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and all Federally Qualified Health Center claims. Providers may continue to submit these claims, but payment will not be released until the hold is lifted.

Absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency took effect again for services that are not behavioral health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications that require a face-to-face encounter. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage (ABN). Further information on use of the ABN, including ABN forms and form instructions: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-abn. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action. For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can furnish and receive payment for covered telehealth services under these special telehealth flexibilities. For more information: https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf (PDF).

After a similar proposal died this spring in the Senate, a House Republican on Friday renewed a push to pass a bill that would lead to cities, counties and other government agencies paying more in lawsuits over people getting injured. Rep. Fiona McFarland, R-Sarasota, filed a bill (HB 145) that would revamp the state’s sovereign-immunity laws, which help shield government agencies from costly lawsuits. Under a law passed in 2010, government agencies’ liability in such cases is capped at $200,000 for payments to a single person and $300,000 if multiple people are involved in an incident, though the caps can be exceeded if lawmakers pass a special type of measure known as a “claim” bill. Under McFarland’s proposal, those limits would go to $500,000 and $1 million for injuries that occur on or after Oct. 1, 2026, and $600,000 and $1.2 million for injuries that occur on or after Oct. 1, 2031. The bill could lead to higher costs for government agencies, but McFarland has long argued that changes are needed to sovereign-immunity laws to help victims get justice for injuries. The House voted 103-11 to pass the similar bill during the 2025 legislative session, but the Senate did not take up the issue. McFarland’s new bill will be considered during the 2026 session, which will start in January.

Source: https://www.newsserviceflorida.com/latest/briefs/higher-liability-limits-sought/article_f8bb9c40-316f-4089-a5c0-1ecb134cc3b9.html

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Those programs collectively receive about $9 billion, but funding will shrink to $5.2 billion by fiscal year 2034-35. The Hospital Directed Payment Program, which accounts for the largest share at $8.1 billion this year, will see a $3.5 billion reduction by 2034. Other affected initiatives include the Physician Supplemental Payment Program, down $234 million, the Public Hospital Physician Program, down $9 million, and two Florida Cancer Hospital Programs, down $56 million and $17 million. Meyer said the cuts will be phased in gradually. "What this provision does is any state-directed payments that are above 110% of Medicare beginning in 2028 will start stepping down annually 10% a year until you get to the 110% of Medicare threshold," he said. "We currently have five state-directed payment programs that are above 110% that will need to be stepped out. Depending upon where they are with respect to the percent of Medicare, some will get to that 110% cap sooner," he added. "Others will take more years to get there at a 10% annual reduction." The discussion came as House lawmakers met for the first committee week ahead of the 2026 legislative session scheduled to begin on Jan. 13, focusing on health care access and affordability — issues likely to dominate debate as Florida braces for the long-term fiscal impact of the federal reforms.

Source: Florida Politics

The Florida House next week could start a renewed effort to change state law to clear the way for some people to pursue medical-malpractice lawsuits over the deaths of family members. The House Civil Justice & Claims Subcommittee is scheduled Oct. 15 to take up the proposal (HB 6003).

The bill, sponsored by Rep. Dana Trabulsy, R-Fort Pierce, is filed for consideration during the 2026 legislative session, which will start in January.

Lawmakers passed such a proposal during the 2025 session, but Gov. Ron DeSantis vetoed it.

The proposal would repeal a 1990 law that prevents people ages 25 and older from seeking what are known as “non-economic” damages in medical-malpractice cases involving deaths of their parents.

Also, under the law, parents cannot seek such damages in malpractice cases involving the deaths of their children who are 25 or older.

People who allege their family members were killed by malpractice supported the proposal throughout the 2025 session, arguing that doctors and other health providers are not being held accountable.

But health-care and business groups lobbied against the change, contending it would drive up malpractice insurance costs and lead to doctors deciding not to practice in Florida. In vetoing the proposal, DeSantis said it could open “floodgates” for litigation.

A House panel next week will hold a discussion about use of artificial intelligence in the insurance industry, after lawmakers during the 2025 session considered placing restrictions on AI in claims handling. The House Insurance & Banking Subcommittee is scheduled Tuesday to take up the issue. The House and Senate during the 2025 session considered bills that would have prevented insurers from using artificial intelligence as the sole basis for denying claims. The bills did not pass. House and Senate panels will start meeting Tuesday as lawmakers prepare for the 2026 session, which will start in January.

Absent Congressional action, beginning October 1, 2025, many of the statutory limitations that were in place for Medicare telehealth services prior to the COVID-19 Public Health Emergency will take effect again for services that are not behavioral and mental health services. These include prohibition of many services provided to beneficiaries in their homes and outside of rural areas and hospice recertifications that require a face-to-face encounter. In some cases, these restrictions can impact requirements for meeting continued eligibility for other Medicare benefits. In the absence of Congressional action, practitioners who choose to perform telehealth services that are not payable by Medicare on or after October 1, 2025, may want to evaluate providing beneficiaries with an Advance Beneficiary Notice of Noncoverage. Practitioners should monitor Congressional action and may choose to hold claims associated with telehealth services that are not payable by Medicare in the absence of Congressional action. Additionally, Medicare would not be able to pay some kinds of practitioners for telehealth services.

For further information: https://www.cms.gov/medicare/coverage/telehealth.

CMS notes that the Bipartisan Budget Act of 2018 allows clinicians in applicable Medicare Shared Savings Program Accountable Care Organizations (ACOs) to provide and receive payment for covered telehealth services to certain Medicare beneficiaries without geographic restriction and in the beneficiary’s home. There is no special application or approval process for applicable ACOs or their ACO participants or ACO providers/suppliers. Clinicians in applicable ACOs can provide these covered telehealth services and bill Medicare for the telehealth services that are permissible under Medicare rules during CY 2025, irrespective of further Congressional action.

For more information:

https://www.cms.gov/files/document/shared-savings-program-telehealth-fact-sheet.pdf.

MACs will continue to perform all functions related to Medicare Fee-for-Service claims processing and payment.

TALLAHASSEE — Three major hospital systems have challenged a new state proposal about approving organ-transplant programs, alleging it does not include adequate safeguards for quality of care.

Tampa General Hospital, UF Health Shands Hospital in Gainesville and Jackson Memorial Hospital in Miami filed the challenges after the Florida Agency for Health Care Administration in August issued a proposed rule for transplant programs. The challenges, filed this month at the state Division of Administrative Hearings, came after years of debate and disputes about approving transplant programs.

Tampa General, UF Health Shands and Jackson provide procedures such as heart, liver, lung and kidney transplants. The proposed rule, in part, would revise standards for hospitals that want to begin providing such procedures. — and continue providing them after getting initial approvals.

“For instance, the proposed rule does not require an organ transplant program to perform a minimum number of transplants each year, which would provide assurance to patients that the program’s physicians and staff are experienced and have performed this complicated procedure enough to be proficient,” Tampa General’s petition at the Division of Administrative Hearings said. “Nor is there a minimum outcome standard that would compare each transplant program’s actual outcomes to their expected outcomes. As a result, if this proposed rule were adopted, the agency would have no authority to take any action against an organ transplant program that is performing only one or two transplants per year with minimally experienced staff, or that has substantially worse patient outcomes compared to what was expected.”

A joint petition filed by UF Health Shands and Jackson raised similar arguments, while also saying the proposed rule could have spin-off effects on hospitals already performing transplants.

“Additionally, the proliferation of low-volume, low-quality programs endangers existing programs, like Shands and Jackson, by siphoning off patients from existing programs,” the UF Health Shands and Jackson petitions said. “This is highly concerning for existing programs, since there are only a limited number of organ transplant cases in the state of Florida. Decreasing the volume of organ transplant patients for existing programs could impact the programs’ viability and quality of care.”

Florida long used what is known as a “certificate of need” process to determine whether hospitals should offer transplant procedures. While supporters said the process helped ensure quality of care and hold down costs, opponents argued it created artificial barriers in the health-care system and limited competition.

The Legislature in 2018 passed a law directing the Agency for Health Care Administration to adopt licensure standards for organ-transplant programs that were separate from the certificate of need process, according to the petition filed this month by UF Health Shands and Jackson. In 2019, the Legislature repealed the certificate of need process.

The moves came after disputes about approval of transplant programs — and a broader push by lawmakers to eliminate certificate of need processes.

The petition filed by UF Health Shands and Jackson said that with the “elimination of the certificate of need process for transplants, the new licensure standards for organ transplant programs became even more important, since they would now be the only governing licensure standards over organ transplant programs in the state of Florida, laying out for both new applicants and existing programs the standards to establish and maintain an organ transplant program.”

An initial proposed rule drew opposition, including from Tampa General, UF Health Shands and Jackson, and was ultimately withdrawn in 2021. The new proposal was filed Aug. 19.

The petitions filed this month raised a series of arguments under administrative law, including that the proposed rule is an “invalid exercise of delegated legislative authority.” Part of that argument, for example, is whether the proposed rule carries out requirements of the 2018 law to include quality-of-care standards.

The report shows that physicians deliver care to patients in practices that are increasingly owned by hospitals or other organizations and not by physicians, larger, and increasingly likely to include physicians in a variety of specialties, not just one.

The report also explores the reasons that private practices are sold to hospitals, private equity firms, or insurers and finds that inadequate payment rates, costly resources, and burdensome regulatory and administrative requirements are longstanding and important drivers of this change.

Other reports based on the Benchmark Survey can be found here. 

WASHINGTON, DC—JUNE 23, 2025—U.S. Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. and Centers for Medicare & Medicaid Services (CMS) Administrator Dr. Mehmet Oz today met with industry leaders to discuss their pledge, links to an external website , opens in a new tab  to streamline and improve the prior authorization processes for Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace® and commercial plans covering nearly eight out of 10 Americans.

In a roundtable discussion hosted by HHS, health insurers pledged six key reforms aimed at cutting red tape, accelerating care decisions, and enhancing transparency for patients and providers. Their commitments reinforce the role of CMS in monitoring outcomes and promoting accountability. Companies represented at the roundtable included Aetna, Inc., AHIP, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Centene Corporation, The Cigna Group, Elevance Health, GuideWell, Highmark Health, Humana, Inc., Kaiser Permanente, and UnitedHealthcare.

“Thank you to the insurance companies for making these commitments today. Americans shouldn’t have to negotiate with their insurer to get the care they need,” said Secretary Kennedy. “Pitting patients and their doctors against massive companies was not good for anyone. We are actively working with industry to make it easier to get prior authorization for common services such as diagnostic imaging, physical therapy, and outpatient surgery.”

“These commitments represent a step in the right direction toward restoring trust, easing burdens on providers, and helping patients receive timely, evidence-based care,” said Administrator Oz. “We applaud these voluntary actions by the private sector, which is how these types of issues should be solved. CMS will be evaluating progress and driving accountability toward our shared goals, as we continue to champion solutions that put patients first.”

Participating health insurers have pledged to:

• Standardize electronic prior authorization submissions using Fast Healthcare Interoperability Resources (FHIR®)-based application programming interfaces.
• Reduce the volume of medical services subject to prior authorization by January 1, 2026.
• Honor existing authorizations during insurance transitions to ensure continuity of care.
• Enhance transparency and communication around authorization decisions and appeals.
• Expand real-time responses to minimize delays in care with real-time approvals for most requests by 2027.
• Ensure medical professionals review all clinical denials.

Praise from members of Congress regarding today’s developments:

“It was an honor to attend this discussion with Secretary Kennedy and CMS Administrator Dr. Oz,” U.S. Senator Roger Marshall, M.D. (R-KS) said. “This is an important topic that has continued to be an issue for far too long. I applaud the leadership of Secretary Kennedy and President Trump for bringing us all to the table to find solutions for our patients and providers.”

“Thank you to President Trump, Secretary Kennedy, and Administrator Oz for working to improve the prior authorization process for American patients,” Congressman Greg Murphy, M.D. (R-NC) and co-chair of the House GOP Doctors Caucus, said. “As a physician for over 30 years, I witnessed the ridiculous and ever-increasing obstructions caused by insurance companies to delay or deny care to patients. These bureaucratic hurdles end up hurting patients and those who care for them. Practices have had to hire many more staff just simply to fight with insurance companies. I have made reform a top priority of mine since coming to Congress. I am grateful for the collaborative effort by stakeholders to make commitments to streamline approvals and look forward to them delivering on this pledge.”

These private sector reforms complement ongoing regulatory efforts by CMS to improve prior authorization interoperability within Medicare Advantage, Medicaid Managed Care, Health Insurance Marketplace®.

CMS encourages continued innovation and collaboration but reserves the right to pursue additional regulatory actions if necessary.

Get CMS news at cms.gov/newsroom, sign up for CMS news via email, links to an external website , opens in a new tab  and follow CMS on X (Formerly Twitter) @CMSgov

Claiming the bill lacked "safeguards like caps on damages and attorney's fees," DeSantis described his decision as driven by financial considerations, aiming to keep Florida appealing to physicians and preserve the state's quality of health care while its insurance market continues to stabilize. "This legislation would increase costs to provide healthcare services to Floridians, especially in our rural and aging communities, expose Florida's physicians and healthcare providers to unpredictable liability, drive physicians to leave the state, and incentivize lawyers to bring unmeritorious claims," the governor's veto letter reads. "None of this improves quality, access, or outcomes for Florida families."

In 1990, Florida became the only state to differentiate medical malpractice from other types of wrongful death by including an exception in its medical-malpractice laws that prevented a narrow group of people from pursuing damages in lawsuits over the deaths of family members. The bill (HB 6017), which overwhelmingly passed both chambers during the spring legislative session, would allow adult children over 25 and the parents of adult children to seek non-economic damages, such as pain and suffering, when a family member dies due to medical negligence and is unmarried with no minor children.

Prior to the proposal's passage, the Senate rejected an amendment that the governor supported, which would have included a $1 million cap on non-economic damages in all medical wrongful death cases. DeSantis defended current law, saying it "provides several mechanisms, including a regulatory framework, to hold bad actors accountable and recover damages when a family chooses to pursue a wrongful death claim," and suggested the lawmakers include safeguards in future legislative efforts to avoid making a "legal landscape ripe for predatory trial attorneys." Meanwhile, House bill sponsor Rep. Dana Trabulsy, R-Fort Pierce, said she "would like nothing more than a veto override," while the Senate sponsor, Jacksonville Republican Sen. Clay Yarborough, stated that although he "wanted to see the bill become law," he accepts and respects the governor's decision, adding that he is "not advocating for a veto override." During the committee process, supporters of the repeal shared heartbreaking and emotional stories of losing loved ones with no legal recourse under current law. Opponents, including medical professionals, hospital groups and the governor, warned the change could worsen Florida's physician shortage and raise insurance costs. The House passed the measure on a 104-6 vote in March, while it cleared the Senate on a 33-4 vote in early May. While both chambers have the votes to override the governor's veto, it would be a rare move for the Legislature. 

The hospital ranked fourth nationally in 2023 with 756 transplants. This year, the hospital surpassed other leading centers, including the Mayo Clinic in Arizona with 883 transplants, according to data from the Organ Procurement and Transplantation Network. 

The state of Florida ranked second nationally for organ transplants in 2024, with 3,250 procedures, nearly a third of which were conducted by Tampa General. California led the nation with 5,261 transplants. 

Tampa General Hospital's Transplant Institute, which celebrated its 50th anniversary in 2023, has completed more than 14,000 transplants since its inception. In March, the hospital completed its first of three heart and lung transplants.

Overall, the facility's transplant procedures included 500 kidneys (110 from living donors), 279 livers (five from living donors), 51 hearts, 42 lungs, 14 kidney-pancreas, and three heart-lung. 

WUSF / TGH Press Release