For nearly all acute care hospitals in the United States, a new mandatory payment model is on the horizon. The Centers for Medicare and Medicaid Services (CMS) has proposed the Comprehensive Care for Joint Replacement Expanded (CJR-X) Model, a mandatory, nationwide, episode-based payment model for lower extremity joint replacements (LEJRs) in Medicare fee-for-service (FFS). If…

V28 is no longer a transition issue. It is the live operating environment for Medicare Advantage risk adjustment in 2026. CMS completed the three-year phase-in of the 2024 CMS-HCC model for CY 2026, meaning plans and providers are now operating under the full model rather than a blended version. That makes mid-year the right moment…

Provider health systems and hospitals are under growing pressure to assume greater financial accountability for the total cost of care. Federal and state payers and some commercial health plans are accelerating the move from fee-for-service (FFS) payments to value-based care (VBC) models, including high-risk hospital global budget models. Hospital global budget methodologies establish fixed annual…

While reviewing claims data patterns in quarter three (Q3) of 2025, Milliman observed a significant increase in paid amounts for claims billed under Healthcare Common Procedure Coding System (HCPCS) code A4352—intermittent urinary catheter; coudé (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each—that deviates from historical trends and could have…

The transition towards value-based care (VBC) is rapidly reshaping the healthcare landscape. While this shift holds immense promise for improving patient outcomes and reducing costs, it also presents a unique set of challenges that demand careful consideration for successful contract negotiations and management. In this blog post Milliman MedInsight product manager, Umang Gupta, explains the…