Bobbi Buell's Newsletter

Roberta L. Buell is a Principal at onPoint Oncology Inc., specializing in oncology reimbursement. With over 23 years of experience in billing, coding, and drug therapy reimbursement, she's a nationally recognized expert and frequent speaker on regulatory and reimbursement issues. Bobbi has led more than 600 seminars since 1991 and currently serves as content director for focalPoint® and assistPoint®. Learn more about Bobbi here .

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January 2026

Medicare Wants to Overhaul Claims

How many of you have been through a Medicare or other payer claims adjudication system conversion? A few of them in my lifetime have been ok, while others have been unmitigated disasters, with delays, incorrect claim determinations, and mismatches between policies and claims. This proposed program (it is not a proposed rule) is the blend of FOUR legacy systems written in COBOL (programming from ancient digitheads). Think of a billing system conversion times 100. This is why you should be aware of this NOW before it goes any further. This is a REQUEST FOR INFORMATION--it is not a proposed rule, not a directive, not an executive order. CMS (Claims Might Suck) just wants COMMENTS for now. And, it is a good idea to comment before it's too late. As a spoiler alert, I will posit that there is too much emphasis on fraud and waste. Every administration believes it can pull money out of the air by finding more fraud. Here's a bit about the Request for Information, including objectives and…

January 2026

How's It Going With Prior Auth?

Health insurers pledged in June 2025 to overhaul their processes as part of a Trump administration initiative to reduce the volume of prior authorization requirements and modernize how requests are handled. According to AHIP (Association of Health Insurance Plans), they pledged to the following goals for January 1, 2026 Reducing the Scope of Claims Subject to Prior Authorization. Individual plans have committed to specific reductions to medical prior authorization as appropriate for the local market each plan serves. Ensuring Continuity of Care When Patients Change Plans. When a patient changes insurance companies during a course of treatment, the new plan honors existing prior authorizations for benefit-equivalent in-network services as part of a 90-day transition period. This action is designed to help patients avoid delays and maintain continuity of care during insurance transitions. Enhancing Communication and Transparency on Determinations. Health plans should provide clear…

January 2026

Two New Drug Demos PROPOSED

On December 23, 2025 (while you were drinking eggnog), CMS published two proposed rules intended to activate the Trump Administration’s stated policy goal of aligning U.S. pharmaceutical pricing with that of other so-called developed countries using “most favored nation” comparisons. The proposed rules— Global Benchmark for Efficient Drug Pricing (“GLOBE”) in the case of Medicare Part B, and Guarding U.S. Medicare Against Rising Drug Costs (“GUARD”) will be managed and fall under the agency’s Innovation Center payment ("CMMI")and service model demonstration and waiver authority. As proposed, the models would test alternative methods for calculating manufacturer rebates under the Medicare Part B and Part D inflation rebate programs by tying applicable pricing benchmarks for model drugs to international pricing information, among other changes. Comments on the proposed rules are due on February 23, 2026 This article explains: a very high-level overview of the proposals, potential…