Prior Authorization & Compliance

The Two-Midnight Rule was supposed to be settled. It was finalized more than a decade ago. CMS extended it to Medicare Advantage plans starting January 1, 2024. On November 25, 2025, CMS issued further clarifying updates in the CY 2026 OPPS Final Rule. By every reasonable measure, this should be a closed chapter. It isn't. Status determination errors — the wrong choice between inpatient and observation, the downgrade after the fact, the denial that should never have been issu

What the First Public Prior Auth Denial Reports Reveal — and How to Use Them at the Negotiation Table For the first time in history, hospitals can pull up a payer's website and see — in black and white — how often that payer denies prior authorization requests, how long they take to decide, and how many of those denials get overturned on appeal. The data is public. The accountability is new. And most hospital finance teams haven't done a thing with it. Under the CMS Interoper

Key Takeaways 1. The CMS Physician Fee Schedule Lookup Tool Is Your Authoritative Payment Rate Source The official CMS tool (https://www.cms.gov/medicare/physician-fee-schedule/search) provides accurate, current payment information for over 10,000 services. Use it regularly for budgeting, coding verification, and contract negotiation. It offers three search methods: by specific code (fastest), by keyword (helpful when you know the service but not the code), or by code range (