Originally published by https://www.cms.gov/newsroom/blog/moving-prior-authorization-21st-century

A common practice imposed by health insurers on patients and providers is their intrepid need to second-guess clinician treatment decisions by requiring prior authorizations before paying a claim. The current prior authorization process creates unnecessary delays for patients, burdens health care providers with excessive paperwork, and erodes trust between payers and health care providers, even though all share the same goal: delivering high-quality patient care.

When a health care provider orders a test, procedure or medication, the paper-based prior authorization process can drag on for days or even weeks. Clinicians and their staff waste hours filling out paper forms on clipboards, faxing them to insurers, and waiting around for phone calls. Completing prior authorizations costs health care providers $20-50 per hour and takes an average of 13 hours per week. On average, that’s nearly $34,000 and 700 hours a year per health care provider that could otherwise be spent caring for patients. 

It is way past time to axe the fax, kill the clipboard, and put patients over paperwork.

Last year, the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS) announced a landmark pledge with major health plans from across the country to streamline and improve the prior authorization process across the entire health care industry. This pledge reflects a shared commitment to modernizing prior authorizations to create a more responsive, patient-centered experience. 

Since then, the health care industry has already begun delivering results. For example, leading health plans announced in April that they eliminated 11% of prior authorizations across a range of medical services, representing 6.5 million fewer prior authorizations for patients. Other plans are rapidly scaling standardized processes and reducing requirements, demonstrating that meaningful change is not only possible—it’s happening. For example, one large national plan is eliminating authorization requirements for 30% of healthcare services and has committed to reviewing and removing additional requirements. 

CMS is proud to announce the next chapter of that commitment: adding electronic prior authorization to the Health Tech Ecosystem. The initial landmark pledge effort brought the nation’s major health plans to the table. This new initiative brings everyone else. Health systems, hospitals, physician practices, electronic health record (EHR) vendors, and digital health developers are now joining payers as a unified coalition aligned around a single mission: making electronic prior authorization work end-to-end, on time, for every patient. 

Committed working groups across these stakeholders will align on CMS Interoperability and Prior Authorization Final Rule deadlines, addressing workflow gaps and technical handoffs that no single sector can fix alone. Prior authorization touches every part of the health care system; now, every part has a seat at the table.

CMS has also been working with EHR vendors to streamline and digitize the prior authorization process for medical items and services. As of January 1, 2026, impacted payers across Medicare Advantage, Medicaid & Children’s Health Insurance Program (CHIP) and Marketplace (Federally-facilitated Exchange) plans are required to send prior authorization decisions for medical items and services within 72 hours for expedited (urgent) requests and 7 calendar days for standard (non-urgent) requests. 

Electronic prior authorization interfaces from these payers will go live on January 1, 2027, and their use will eventually be incorporated into the Medicare Promoting Interoperability Program for hospitals and the Merit-based Incentive Payment System (MIPS) for clinicians. These policies will reduce burden on patients, health care providers, and payers, saving approximately $15 billion over 10 years. 

CMS is also building on these efforts by proposing major reforms to expand electronic prior authorization to drugs. 

This transformation extends well beyond any single agency or payer. Modernizing prior authorization is a catalyst for a broader realignment of the health tech ecosystem, bringing together EHR vendors, health plans, clearinghouses, pharmacy benefit managers, and digital health developers around a common set of standards: National Council for Prescription Drug Programs (NCPDP) for pharmacy benefit drugs and Fast HealthCare Interoperability Resources (FHIR®) Standards for medical items and services.

CMS has engaged extensively with the health tech community, working with vendors to embed electronic prior authorization directly into EHRs, and with health IT developers to ensure that implementation guides reflect real-world workflows. This ecosystem-wide coordination is what separates this effort from previous attempts at prior authorization reform. When data flows seamlessly -- between a provider’s EHR, the payer’s electronic prior authorization interfaces, and a patient’s health record -- the entire system becomes more responsive, more accountable, and more focused on what matters most: getting patients the care they need without unnecessary delays or burdens. 

If you’re a health care provider, you can visit our Electronic Prior Authorization webpage to learn more and get started. 

CMS is committed to reducing administrative burden on health care providers, strengthening patients’ access to care, and promoting interoperability across the health care ecosystem and will continue to pursue innovative solutions to achieve those goals.

View a video message from me and a timeline highlighting the progress CMS is making on improving prior authorization. 

APRN autonomous practice: The Board of Medicine is reviving the Council on APRN Autonomous Practice to review oversight and standards related to autonomous practice, following concerns about scope and enforcement. The council is expected to reconvene later this year.

Physician assistant supervision: Proposed rule changes would remove the phrase “reasonable physical proximity” and continue to rely on a broader “responsible supervision” standard that considers factors such as patient risk, task complexity, physician availability and practice setting.

Read the full FMA regulatory update here.

Source: WUSF Public Media, with reporting from News Service of Florida

Both measures were priorities for Gov. Ron DeSantis before his term ends in January, but House Speaker Daniel Perez announced members will vote on redistricting and be dismissed.

The Florida House won’t take up bills to eliminate vaccine exemptions and create artificial intelligence guidelines at this week’s special session, as Gov. Ron DeSantis expected.

On Tuesday, as lawmakers opened the session primarily aimed at redrawing congressional districts, House Speaker Daniel Perez said the ancillary issues are off the table this week because no bill was filed in his chamber.

Perez said House members will be free to return home after Wednesday’s vote on redistricting.

“There are, of course, other issues contained in the call; however, there were no bills filed on these policies prior to the start of this special session,” Perez said. “Consequently, we will not be taking up those issues.”

The vaccine and AI issues were top priorities for the governor, who postponed the special session a week to make a final push before his term ends in January.

Also Read: Florida's redistricting session is delayed as DeSantis adds AI and vaccines

Perez's move means the medical freedom bill “seems dead in this special session,” said Aubrey Jewett, a professor of political science at the University of Central Florida.

“Both the House and the Senate have to pass the same version of the bill and send it to the governor, and the speaker has made a pretty clear declarative statement that they are not taking up medical freedom,” Jewett said.

“And thus, if the House isn't going to take it up, it's just not going to go anywhere. It's not going to become law, not this special session.”

Florida's former surgeon general Scott Rivkees also applauded the move.

“This shows what happens when common sense, the public voice, and strong rooted medical practice prevails over fringe science,” Rivkees told WUSF.

“One thing that I learned from my time in Tallahassee is that politicians listen to the public. With recent polling showing overwhelming support for required school vaccines, it is not surprising that legislation that would topple a clear public health success would not go through.”

“Voters elected Republicans to protect freedom against both the Big Tech cartel and the medical industrial complex,” DeSantis wrote on X after Perez’s announcement. “Yet, when given the chance to deliver for their constituents, not a single Republican House member could even be bothered to file a bill. Typical political shenanigans.”

During the regular legislative session this spring, the vaccine bill was supported by parents' rights advocates and opposed by medical professionals worried it could lead to a larger spread of preventable diseases.

Also Read: Florida's DeSantis unveils a voting map that could add to Trump's GOP redistricting

During the regular session, the Senate passed a version of the measure, but it received no attention in the House. On Friday, bill sponsor Sen. Clay Yarborough, R-Jacksonville, refiled an identical measure.

The bill (SB 6D) would have expanded vaccine exemptions for K-12 schools, creating a new “conscience” category for parents to opt out of immunizations. It also would have required health care workers to provide alternative vaccine schedules for children and make ivermectin available without a prescription.

Florida’s surgeon general would also be stripped of the power to require a vaccine during a public health emergency under the bill.

Also Read: So far, Florida has failed to end vaccine mandates. Now there's a last-ditch effort

The bill, though, would have fallen short of Florida Surgeon General Dr. Joseph Ladapo’s push to repeal all vaccine mandates.

Since then, the Department of Health started the rulemaking process of repealing requirements for Hepatitis B, varicella (chicken pox), Haemophilus influenza type b (Hib) and pneumococcal conjugate vaccines for public school attendance.

The repeal of the measles, mumps and rubella vaccine, polio, diphtheria, rubeola and tetanus vaccines, however, required legislative action. No legislator filed a bill to remove those requirements from Florida law this year.

Source: Adapted from reporting by WUSF Public Media, with information from News Service of Florida.

Read original article at WUSF

Source: KFF Health News

Florida’s delayed KidCare expansion leaves thousands of children in coverage limbo

Like many parents, Tatiana Lafortune wants her children to get a good education, eat nutritious food, and see a doctor when they’re not feeling well.

Public schools and her church’s pantry help with the first two. But insurance to cover doctor visits has been the most difficult to secure.

As nursing assistants near Tampa, Lafortune and her husband cannot afford employer coverage and earn too much for subsidized coverage through Florida KidCare.

Unable to afford KidCare’s full-price premium, she purchased a marketplace plan with higher out-of-pocket costs and no dental coverage.

“KidCare is better for children,” she said. “But at least I have something for them.”

In 2023, Florida lawmakers unanimously approved expanding KidCare eligibility to cover more than 40,000 additional children, but the expansion has not taken effect despite federal approval.

Instead, implementation has been stalled by lawsuits and ongoing disputes between the state and federal regulators.

“I don’t know what they’re waiting for,” Lafortune said. “They should see people in Florida have needs.”

Entitlement vs. Personal Responsibility

At issue is a federal rule requiring 12 months of continuous coverage for children enrolled in Medicaid and CHIP programs, including Florida KidCare.

Florida has challenged the rule in court and delayed its planned expansion, while continuing to disenroll children for unpaid premiums.

Advocates argue the delay may violate federal law and undermines child health coverage.

“It’s something that goes back to this mentality of people needing to pull themselves up by their bootstraps,” said Melanie Andrade Williams of the Florida Health Justice Project.

Health policy advocates also note Florida’s position conflicts with broader efforts to improve child wellness and reduce uninsured rates.

Florida and Texas have among the nation’s highest numbers of uninsured children.

Choosing Between School Supplies and Health Insurance

According to Florida Healthy Kids Corp., roughly 43,000 children lost subsidized coverage after parents missed premium payments.

Advocates say missed payments often occur when families must choose between essentials like school supplies, holiday expenses, and health insurance.

“You have working parents here who are struggling and they have to choose between their child’s school supplies and their health insurance,” said Joan Alker of Georgetown University.

Meanwhile, lawmakers recently redirected $32 million in KidCare surplus funds to the general fund, drawing criticism as expansion remains stalled.

The proposed expansion would raise income eligibility and provide more affordable, comprehensive coverage than many ACA marketplace plans, including dental and vision benefits.

For families like Lafortune’s, the delay has real consequences as insurance costs continue to rise.

“I tried to get something cheaper, but it’s not like I cannot have it,” she said. “I have to do something.”

As legal challenges continue, advocates say thousands of children remain at risk of losing or lacking affordable coverage.

“Children are the ones who are going to replace everyone here,” Lafortune said. “When you give them opportunities — for their health, for school, to eat — you make your country healthy and better.”

Adapted from reporting by KFF Health News.

Read the full article at KFF Health News

Florida’s measles outbreak appears to have slowed down. However, measles counts continue to rise throughout the country.

In the latest available data for March (March 1 through March 28), the state reported 21 new cases – a remarkable drop off from the 123 cases between January and February, according to the Florida Department of Health.

The Centers for Disease Control and Prevention labels measles as one of the most contagious diseases in the world. The airborne virus can cause coughing, fever, red eyes, and a rash. Measles is especially dangerous for babies and young children.

The diminished spread of measles is a good sign, but Florida’s overall case numbers for the first three months are highly unusual. The state’s online public database shows measles cases starting from 1992. This year recorded more than triple Florida’s previous highest year (1992) for measles, and accounts for a third of all Florida’s cases.

Most cases this year – 106 – have been reported in Collier County, where students of Ave Maria University were diagnosed.

Central Florida has remained relatively unscathed by the outbreak, but one case was reported in early March out of Osceola County. The patient was in the 25-29 age group and was infected “in the U.S. outside of Florida,” according to state data.

Central Florida Public Media reached out to the Department of Health in Osceola County regarding what county residents should know about the case.

“Residents are encouraged to visit the Florida Department of Health’s website for information on the illness and what to do if exposed,” it said in a written response.

Florida ranks fourth highest in the country for measles cases. South Carolina (668), Utah (318), and Texas (170) lead the country.

So far, the CDC has reported 1,575 cases around the U.S., which is more than half of all the cases recorded in all of last year, which came to 2,285.

Experts say the reason measles is surging is because of low rates of people receiving the MMR vaccine, which is a two-shot immunization, usually administered by age 6.

“Herd immunity” against measles is achieved when 95% of a population is inoculated. Florida’s kindergarten population was reported to be 88.8% inoculated, according to the CDC.

While it's recommended for children to receive the MMR vaccine and its booster before turning 6 years old, anyone can get vaccinated at any stage of life at a retail pharmacy.

Florida aimed to become the first state in the nation to end all vaccine mandates. But lawmakers failed to agree on a path forward.

Seven months ago, Florida was poised to become the first state in the nation to make vaccines totally optional after state Surgeon General Dr. Joseph Ladapo decried mandates as “wrong” and dripping “with disdain and slavery.”

The state Department of Health “is going to be working to end all vaccine mandates in Florida law. All of them!” he announced to thundering applause at a September press conference alongside Gov. Ron DeSantis.

But an effort to change rules by the department appears to have stalled. And a watered-down version of an anti-mandate bill appeared in this year's legislative session but failed to advance in both chambers.

“Maybe they saw this wasn't going to be as politically popular for them to do,” said Simone Chriss, a civil rights attorney with Southern Legal Counsel.

ALSO READ: Florida plans to remove vaccine mandates. What does that mean for schools?

Chriss attended a public workshop, hosted in December in Panama City by the health department, to discuss the proposed removal of four vaccines from the state’s rules for entry into day cares and schools.

The state agency can remove vaccine requirements for varicella (chickenpox), hepatitis B, pneumococcal conjugate and haemophilus influenzae type B. Other vaccinations, like those against measles (MMR) and polio, are written into state law and would have to be changed by the Legislature.

Public comment went on for hours, with proponents of the changes spoke of the right to medical freedom and claimed injury from vaccines.

Major medical groups and pediatricians spoke in favor of routine immunizations, warned of an upsurge in the diseases and deaths vaccines prevent, and the need for 95% of children to get their shots to maintain herd immunity and protect people with compromised immune systems.

At that meeting, when questioned by Chriss, health department officials admitted they had not studied the regulatory costs of removing mandates, which is required by law and includes the costs of revising or updating all the systems used by schools and pediatricians across the state.
“Another thing they are required by statute to do is to hold workshops open to the public – and it specifically says in various regions of the state or the agency service area,” Chriss added.

Those should take place in areas like Tampa, Orlando and Miami, with larger populations than Panama City. No further workshops have been scheduled. Chriss said the health department also hasn’t filed a notice of proposed rulemaking, which is supposed to come within 180 days of the notice to initiate the change.

“Nor have they responded to any of the requests for information about the impact on human lives and health and safety,” Chriss said.

Asked for an update, the health department told WUSF it is “currently in the rulemaking process,” but gave no details.

In a September 2025 CNN interview, Dr. Joseph Ladapo insisted the vaccination issue was about medical freedom and and parents' rights, as anchor Jake Tapper questioned him about the risks of removing mandates.

Soon after Ladapo’s announcement in September, CNN’s Jake Tapper asked the surgeon general if the state had done any analysis of how many cases of illnesses could be projected by removing the mandates.

Ladapo answered: “Absolutely not,” and framed the move as being about what's “right and wrong,” and “an issue of parents’ rights.”

Fast forward a couple of months, and a bill (SB 1756) did appear in the Florida Senate. It didn't end vaccine mandates but added another way to opt out by claiming the shots go against personal beliefs. Florida already allows religious or medical exemptions.

Democrats lined up against it.

"It's currently very easy to opt out for religious reasons from school immunizations. Why is this bill necessary?" asked Sen. Carlos Guillermo Smith, D-Orlando, at a hearing. "Is your bill just about giving people more options to ignore school immunizations? Or is it intended to solve a public health problem?"

Sen. Gayle Harrell, R-Stuart, brought up the measles outbreak. Florida has seen more than 140 cases so far this year.

"I truly believe that this is a dangerous bill, and I cannot vote for it," Harrell said.

In the end, the Senate passed the bill. But a House version never advanced, and the effort died in the regular legislative session that concluded March 13.

"We were disappointed that we did not get a bill that was to eliminate all vaccine mandates here in Florida. Instead, we got a bill that did a few things that we liked," said Maija Hahn, who leads the Florida chapter of Children's Health Defense, a nonprofit launched in 2018 by Robert F. Kennedy Jr., now the secretary of U.S. Health and Human Services.

She still holds out hope that something could pop up in a special session on the budget this month.

"If everything is dead, I can say that this year was a very big disappointment. Very big," Hahn said.

The Florida chapter of the American Academy of Pediatrics was involved in lobbying legislators against lifting vaccine mandates.


Dr. Jennifer Takagishi is vice president of the Florida chapter of the American Academy of Pediatrics.
"There was a lot of lobbying, frankly, on both sides," chapter vice president Dr. Jennifer Takagishi said.

The Senate debate, while heated at times, “felt very one-sided in that as a legislator, you should be representing the majority of your constituents, and instead they're siding with a small minority," she added.

A variety of polls show broad support for vaccines, on the order of 8 in 10 people, largely across party lines.

"What we're seeing is, especially for certain childhood vaccines, like MMR (measles, mumps and rubella), parents want vaccine mandates for kids in schools,” said Jen Kates, a senior vice president at KFF, a nonpartisan health policy organization in Washington. “They support these vaccines. They support protecting their kids through these mandates. And that includes Florida parents."

An Associated Press analysis found at least 350 anti-vaccine bills were introduced nationwide last year. Most haven’t passed.

The movement’s most powerful advocates in Florida include DeSantis, whose term as governor ends Jan. 5. Ladapo, who was appointed by DeSantis, could soon follow.

But people on both sides say the fight is far from over, with mistrust of the medical establishment still running high after the COVID-19 pandemic.


"There are many more people now who have skepticism about the wisdom of public health policy and law. And I don't think that that's going to disappear. I think it's going to grow,” said Barbara Loe Fisher, president of the National Vaccine Information Center. She has been working to end mandates since 1982.

“We've been seeing this movement in state legislatures toward protecting the informed consent ethic when it comes to vaccination. And how do you do that? With regard to vaccination, you allow people to make a voluntary decision. You either remove the mandate, or at the very least, you secure flexible medical, religious and conscientious belief exemptions in the law.”

Part of the Florida Senate bill included how it would have required parents who opt in to vaccines, as recommended by their doctors, to get additional “medical information” about the shots. Parents opting out would not be required to get any medical information or counseling.

“If it provided information both ways — we want you to just be educated period, whether you choose to vaccinate or not vaccinate — I would say, OK, maybe there's some validity here," said Chriss. "But to only require that information, seemingly to deter parents who have decided to vaccinate their children from doing so? It feels very disingenuous."

And there’s a lesson there for people in other states, she said.

"I truly think the only thing that has maybe deterred, or maybe just slowed down this process in Florida is the overwhelming number of people that oppose this sort of anti-science removal of vaccine mandates," Chriss added.

Ladapo did not respond to a request for an interview from WUSF, but he briefly acknowledged the situation at an event hosted by the Heritage Foundation in March.

"We have received a lot of pushback, and, you know, push as they might, the positions that we've taken here [are] absolutely the correct moral position," Ladapo said. "I think it's going to work out in the way that it should."

Ladapo's posts lately on social media have increasingly focused on healthy eating, testing candy and baby formula for toxins, and against pesticide use in agriculture.

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“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.

A new economic analysis examining the long-term fiscal impact of reducing Florida’s childhood vaccine requirements projects significant losses to the state’s economy, workforce, and tax base over the next decade.

The report, prepared by the Regional Economic Consulting Group, founded by two former senior state economists, estimates that weakening school-entry vaccine safeguards could reduce Florida’s gross domestic product by $9 billion, eliminate 64,644 jobs, and cut state and local tax revenues by nearly $1 billion over ten years.

More than 90% of the projected economic losses stem from preventable mortality and productivity declines associated with reduced vaccination coverage.

“Policy decisions that reduce vaccination coverage are not cost-neutral,” said Northe Saunders, president of American Families for Vaccines. “This analysis shows that weakening Florida’s long-standing vaccine safeguards would carry measurable economic consequences for families, employers, and state revenues. These are not abstract projections; they reflect lost jobs, lower wages, and reduced economic growth.”

The analysis also forecasts significant regional impacts. Over ten years, projected losses include $2.5 billion in Miami, $1.3 billion in Tampa, $1.2 billion in Orlando, and $717 million in Jacksonville.

“Florida families care about both public health and economic stability,” said Kas Miller, Director of Florida Families for Vaccines. “When vaccination rates decline, outbreaks increase – and that means missed work, higher health care costs, caregiving burdens, and long-term economic damage. Protecting Florida’s vaccine safeguards protects our kids and our economy.”

Health care leaders echoed concerns regarding workforce and community stability.

“Vaccination policies are foundational to keeping children healthy and communities functioning,” said Dr. Rana Alissa, president of the Florida Chapter of the American Academy of Pediatrics. “When preventable diseases return, the effects ripple beyond clinics and hospitals. They disrupt schools, workplaces, and families. Maintaining Florida’s long-standing vaccine safeguards helps prevent illness, protect children, and preserve the stability that communities depend on.”

The report also examined Florida’s tourism economy, warning that a 1% decline in visitor levels due to outbreak concerns could jeopardize $1.3 billion in annual spending and put nearly 7,000 jobs at risk.

“Florida has built one of the strongest economies in the world, and that growth is powered by our people,” said Julio Fuentes, president and CEO of the Florida State Hispanic Chamber of Commerce. “When preventable illness disrupts workforce participation and consumer confidence, the implications for productivity and competitiveness are real. Stability and predictability are essential to Florida’s long-term economic success, and our long-standing vaccine safeguards are a key part of that foundation.”

The findings arrive as lawmakers and state health officials consider potential changes to Florida’s long-standing school-entry immunization requirements.

Tomorrow, the Senate Appropriations Committee will meet to consider SB 1756, a “Medical Freedom” bill that would expand vaccine exemptions, revise parental consent processes, and change how immunization policies are implemented during public health emergencies. The Florida Department of Health is simultaneously considering rulemaking to repeal several long-standing school-entry vaccine requirements.

“Florida’s long-standing vaccine safeguards have helped protect children, support workforce stability, and prevent the kinds of outbreaks that disrupt families and businesses,” said Sen. Gayle Harrell. “When policy decisions affect the health of our communities and also have the potential to affect jobs, tax revenues, and health care costs at this scale, we have a responsibility to consider the full picture.”

REC Group’s modeling also found reduced household earnings of $2.7 billion and increased direct government health care spending exceeding $3 billion over ten years.

“Over 90% of the projected long-term loss, approximately $7 billion of the $9 billion total, is tied to preventable mortality,” said Jared Parker, Founding Partner and Economic Consultant at Regional Economic Consulting Group. “That magnitude of preventable mortality translates into tens of thousands fewer jobs and a measurable reduction in earnings and state revenues.”

The findings mirror recent statewide polling that shows eight in ten Florida voters support maintaining current childhood vaccine safeguards.

The report, Economic Impact of Removing Childhood Vaccine Requirements in Florida, was prepared for American Families for Vaccines.

The Federal Trade Commission secured a landmark settlement with one of the nation’s largest pharmacy benefit managers (“PBMs”), Express Scripts, Inc., and its affiliated entities (collectively “ESI”). The settlement requires ESI to adopt fundamental changes to its business practices that increase transparency, are expected to drive down patients’ out-of-pocket costs for drugs like insulin by up to $7 billion over 10 years, bring millions of dollars in new revenue to community pharmacies each year, and advance the Trump Administration’s key healthcare priorities.

The FTC’s settlement resolves the Commission’s lawsuit against ESI, which alleges that ESI artificially inflated the list price of insulin drugs by using anticompetitive and unfair rebating practices, and impaired patients’ access to lower list price products, ultimately shifting the cost of high insulin list prices to vulnerable patients.

“The FTC’s settlement with Express Scripts is a clear testament to the Trump-Vance FTC’s focus on lowering healthcare costs for American patients,” said FTC Chairman Andrew N. Ferguson. “The FTC’s settlement with ESI will end its business practices that have kept drug prices high, ultimately providing meaningful financial relief to American patients who depend on ESI to access life-sustaining prescription drugs as well as community pharmacies who will see new revenues each year and relief from being squeezed. It also delivers significant wins for the broader Trump-Vance healthcare agenda, including reshoring major portions of ESI’s business, ensuring regulatory compliance with price transparency laws, requiring disclosures of kickbacks to brokers, and paving the way for Americans to participate fully in TrumpRx.”

The FTC’s enforcement action against ESI, as well as Caremark Rx and OptumRx, alleges that the PBMs created a system that artificially drove up the list prices of drugs by preferencing rebates. The complaint alleges that this system pushed insulin manufacturers, among others, to compete for preferred formulary coverage based on the size of rebates off the list price rather than net price, which ultimately benefitted the PBMs, including ESI, which keep a portion of the inflated rebates. According to the FTC’s complaint, the inflated list prices hurt patients whose out-of-pocket payments like copays and coinsurance are tied to the list price of the drug.

ESI, under the FTC’s proposed consent order, has agreed to:

• Stop preferring on its standard formularies high wholesale acquisition cost versions of a drug over identical low wholesale acquisition cost versions;
• Provide a standard offering to its plan sponsors that ensures that members’ out-of-pocket expenses will be based on the drug’s net cost, rather than its artificially inflated list price;
• Provide covered access to TrumpRx as part of its standard offering upon relevant legal and regulatory changes;
  Provide full access to its Patient Assurance Program’s insulin benefits to all members when a plan sponsor adopts a formulary that includes an insulin product covered by the Patient Assurance Program unless the plan sponsor opts out in writing;
  Provide a standard offering to all plan sponsors that allows the plan sponsor to transition off rebate guarantees and spread pricing;
• Delink drug manufacturers’ compensation to ESI from list prices as part of its standard offering;
  Increase transparency for plan sponsors, including with mandatory, drug-level reporting, providing data to permit compliance with the Transparency in Coverage regulations, and disclosing payments to brokers representing plan sponsors;
• Transition its standard offering to retail community pharmacies to a more transparent and fairer model based on the actual acquisition cost for a drug product plus a dispensing fee and additional compensation for non-dispensing services;
• Promote the standard offerings to plan sponsors and retail community pharmacies; and
  
• Reshore its group purchasing organization Ascent from Switzerland to the United States, which will bring back to the United States more than $750 billion in purchasing activity over the duration of the order.

The Commission vote to accept the consent agreement for public comment was 1-0, with Commissioner Meador recused.

The public will have 30 days to submit comments on the proposed consent agreement package. Instructions for filing comments appear on the docket. Once processed, they will be posted on Regulations.gov.

NOTE: When the Commission issues a consent order on a final basis, it carries the force of law with respect to future actions.

The Federal Trade Commission works to promote competition, and to protect and educate consumers. The FTC will never demand money, make threats, tell you to transfer money, or promise you a prize. You can learn more about how competition benefits consumers, file an antitrust complaint, or comment on a proposed merger. For the latest news and resources, follow the FTC on social media, subscribe to press releases, and read our blog.

A Florida Senate committee passed a bill that adds new regulations to e-bikes — and paves the way for more changes in the future.

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.

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.”

Florida’s medical community came out in force at a Department of Health workshop in the state's Panhandle, speaking out against the agency’s move to repeal vaccine requirements for children in public schools.

The meeting was held Dec. 12 in Panama City. Pediatricians and public health workers from Tallahassee, Jacksonville, Naples and Gainesville used their two minutes of public comment time to describe the problems they saw before certain vaccines were available and pleaded with state officials to keep vaccine mandates.

"I'm here to beseech you: please do not change this rule, which will set in motion the dismantling of the successful lifesaving system of public health," said Dr. Paul Arons, former head of the state's HIV/AIDS program from 1989 to 2007. That was before his time was up and the microphone cut off.

The workshop is the first step in repealing a rule that requires Hepatitis B, varicella (chicken pox), Haemophilus influenza type b (Hib) and pneumococcal conjugate vaccines for public school attendance – a move DOH head and State Surgeon General Joseph Ladapo announced in September. (Pneumococcal conjugate vaccines help prevent pneumonia and meningitis, among other illnesses.)

Emma Spencer, the department's director for public health statistics and performance management, said the rule change is "grounded in policy based on considerations that favor parental rights and medical freedom."

Officials at the meeting would not say whether there would be any more workshops, but did say any future public meetings would be posted in the Florida Administrative Register, the state’s official daily publication for proposed rules and public notices.

The state health department also has not yet estimated how much the rule change will cost, which is required by state law.

According to the agency's proposal, the Hepatitis B, chicken pox and Hib vaccinations would not be required for children enrolled in kindergarten through 12th grade. For licensed child care facilities and family daycare homes, chicken pox, Hib and pneumococcal conjugate vaccines will no longer be required.

The state already does allow for religious exemptions "if immunizations are in conflict with the religious tenets and practices of the child's parent or guardian," according to the health department. But it also wants to change this part of the rule, expanding the exemption for any "sincerely held moral or ethical belief."

Officials also want to allow parents, guardians and college and university applicants aged 18-23 the option to decline to participate in documenting their vaccination status in the Florida SHOTS program, which is how the state collects vaccination data.

Parental rights groups and anti-vaccination advocates spoke in favor of the repeal, citing parents' rights and medical freedom. They did, however, repeat unfounded claims, such as pediatricians making money by providing vaccines and that vaccines cause autism.

"The smug way that they sit back there and act like they're above all of us makes me want to throw up," said a speaker named Rick Frye, who wore a grey beanie that said "tin foil."

Many supporters of the rule change also spoke against the measles, mumps and rubella vaccine (MMR), which is not one of the vaccines DOH is able to repeal. That vaccine, along with polio, diphtheria, rubeola and tetanus, requires legislative action. As of Dec. 12, a bill had not been filed for the upcoming legislative session that starts Jan. 13.

GAINESVILLE, Fla. –  The Florida High School Athletic Association (FHSAA) Sports Medicine Advisory Committee (SMAC)—joined by representatives from leading medical organizations and advocacy groups—met this week to finalize recommended updates to FHSAA Bylaw 9 and required forms. These updates will guide the implementation of electrocardiogram (ECG) screening requirements for student-athletes under §1006.20, Florida Statutes (The Second Chance Act), which takes effect July 1, 2026.

The committee approved draft bylaw language and standardized forms, which will advance to the FHSAA Board of Directors for a final vote in early 2026.

Key Highlights
Who Must Obtain an ECG:

• All incoming 9th-grade student-athletes
• Any student in grades 10–12 who has never participated in an FHSAA-sanctioned sports

Returning athletes are not required but strongly encouraged to obtain an ECG. The goal is to identify undetected cardiac risk factors and enhance athlete safety.
Documentation:
A one-page standardized form will confirm ECG completion, including:

• Parent/guardian attestation
• Clinician verification
• Referral information, if needed

Although the form will not be officially released until Board approval in early 2026, families are encouraged to complete screenings early. An ECG performed on or after July 1, 2024 will satisfy the requirement.
Parents can visit WhoWePlayFor.org for local screening opportunities, contact their school athletic director or athletic trainer, or consult their family healthcare provider.

Interpretation Standards To ensure accuracy and minimize false positives, clinicians must use the most current International Criteria for Electrocardiographic Interpretation in Athletes. FHSAA will collaborate with statewide medical societies to provide education and training for consistent application.

Parent Options & School Partnerships The committee reviewed parental opt-out pathways, including religious exemptions, and emphasized the need for schools to partner with qualified ECG screening organizations and referral providers to ensure equitable access for all families.

Please direct any questions to FHSAA SMAC Liaison Scott Jamison. 

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

Whether signing their first physician employment contract in the transition to residency or making a midcareer switch, doctors may be less likely to see the word “quality” come into play in determining their bonuses, according to recent data shared by a leading physician recruiting firm. 

Though opinions may vary on the change’s merit, the trend itself is clear: Data from AMN Healthcare’s Physician Solutions division shows dwindling numbers of their clients’ contracts using quality as a factor for structuring the bonuses paid to physicians.

A look at the data shows that, of the AMN Healthcare searches that offered a bonus in addition to salary, quality was one of the bonus metrics just 16% of the time in 2024–2025. That was down from 26% in 2023–2024, and four times lower than the 64% rate during the 2019–2020 period.

That move away from quality as a deciding factor in bonuses dovetails with what Richard H. Levenstein is seeing. Levenstein, a health care lawyer and shareholder in the prestigious firm Nason Yeager in Palm Beach Gardens, Fla., specializes in health care law and has decades of experience representing physician clients. Over the years, he said, he has seen a shift in the way physician bonuses typically are structured.

“The more significant portions of the bonuses these days are attributable to productivity, [specifically] to RVU production,” Levenstein said.

The use of relative value units (RVUs), which are intended to reflect the amount of work required from a physician for a service, in production bonuses were up slightly in AMN’s data, which showed 65% of contracts having an RVU component in 2024–2025, up from the 57% figure 2023–2024.

AMN Healthcare’s findings were based on a representative sample of the 1,420 search engagements the company conducted from April 1, 2024, to March 31, 2025, and include data on starting salaries and other incentives offered by the company’s clients to physicians across the country. In 935 of those searches, the proposed contracts offered a bonus in addition to salary.

Dive deeper to find out how your specialty stacks up with AMN Healthcare’s 2025 report on physician recruiting incentives. 

Of the bonuses that included quality as a metric of evaluation, the percentage of total compensation tied to quality factors has hovered in between 10% and 16%. Data for the last five years has showed the following percentage of total compensation tied to quality factors in bonuses:

• 2024–2025: 16%.
• 2023–2024: 10%.
• 2022–2023: 14%.
• 2021–2022: 11%.
• 2020–2021: 10%.
• 2019–2020: 11%.

A key question, said Alex Herbison—vice president of AMN Healthcare’s Physician Solutions division—is “what proportion of your total earnings comes from that quality bonus?” 

And, further, “Is that enough to move the needle on behavior if your total compensation—only 16% of it comes from quality? Whereas, if you have an RVU bonus where you can control the volume, you have the chance to make more money.” 

Employers “see the value in that piece as well, obviously, because the patients are getting procedures, the RVUs are rolling in and that means the revenue and the billings are occurring,” Herbison said.

If you are looking for your first job after residency or fellowship, get your cheat sheet from the AMA now. 

Experts and the AMA agree: Due to ever-more complex employment contracts, physicians need the help of an attorney well-versed in health care law to examine contract provisions such as the bonus offerings and to determine how those bonuses might be paid out.

The AMA has teamed up with Resolve, a contract review and negotiation firm specializing in physician employment, to provide custom-contract review to AMA members at a discount. Resolve offers personalized legal experience to help physicians secure the best employment contract terms no matter where they are in their careers. Ready to access your AMA-member Resolve discount? Learn more now. 

Increasingly, “the bonus has become a productivity bonus based upon the number of RVUs above a certain expected level of production,” Levenstein said. “If there are quality metrics—and oftentimes there aren't any—they are a small portion of the bonus.”

Salary remains the largest share of income for physicians, yet bonuses are increasingly factoring into compensation, according to an AMA Policy Research Perspective report (PDF) issued last year that examined trends on physician compensation methods from 2012–2022.

In 2022, 68.2% of physicians received at least some compensation from salary, up from 60.2% in 2012, the AMA report shows. Sole compensation by salary has dropped slightly, however, as more doctors receive a combination of salary and bonus. Looking at this another way, 39% of physicians were compensated by a single method in 2022, compared with 51.8% in 2012.

So, what should physicians entering the job marketplace think of this trend on quality-related bonuses?

That “depends on whether you think quality metrics are a valid measurement. And that depends on how they measure it,” Levenstein noted, adding that “many times when I ask how it [quality] is measured, when there is a quality-metrics bonus component or compensation component, I don't get a real answer because they [the contracts] don't have any objective standards.”

He said that, often, the quality-metric component is “so subjective that it's really almost whatever they want it to be.”

And because of those vagaries, such compensation provisions “can be used to eliminate the bonus or the quality bonus to very little or nothing,” he said.

Quality metrics also sometimes depend on factors that have little to do with the actual quality of the care patients are getting.

“The challenge of quality is there are a lot of variables in there,” Herbison said. “A big part of it is usually patient-satisfaction scores, which is a really tough factor when maybe a patient gives you a bad review because you won't give them the pain medication they want,” for example.

The AMA has policy supporting the idea that “subjective criteria, such as patient satisfaction surveys, be used only as an adjunctive and not a determinative measure of physician quality for the purpose of physician payment.” The AMA also backs the idea that “physician payment determination, when incorporating quality parameters, only consider measures that are under the direct control of the physician.”

By contrast, productivity can be a more clear-cut metric to consider, both for physicians and employers. 

“You get a report of what your productivity is—and you [the physician] should know where you're at, at least approximately, by the amount of services you're providing, the time you're spending, the patients you're seeing” and so on, Levenstein said. “It's a different perspective, a different measurement, and the bonus is completely based upon economics rather than some obscure or subjective quality metrics.”

It is possible for quality metrics, when done in the right way, to help encourage higher-quality care. But too often, Levenstein said, “I don’t think that’s the reality.” 

“Productivity, on the other hand, it's good compensation-wise—it's good for the physician,” he added. “Good physicians still will be good physicians, and they will take good care of their patients.”

Explore further with the AMA STEPS Forward® toolkit, “What to Look for in Your First or Next Practice: 

Evaluate the Practice Environment to Match Your Priorities,” which is enduring material designated by the AMA for a maximum of 0.5 AMA PRA Category 1 Credit™.

Learn more about AMA CME accreditation. 

“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.