Payer
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Alex Wong / Staff via Getty Images
Medicare Advantage plans to share provider directories under CMS final rule
The policy was originally proposed by the Biden administration in November, but comes amid a larger push for more transparency around payers’ provider networks from health officials in the Trump regime.
By Rebecca Pifer • Sept. 19, 2025 -
Courtesy of Blue Shield of California
Kansas, Hawaii Blues invest in Blue Shield of CA’s health tech sister company
Stellarus was launched as part of Blue Shield of California’s restructuring to sell services to nonprofit plans that they don’t have the resources to build themselves. That pitch has now worked on at least two Blues plans.
By Rebecca Pifer • Sept. 18, 2025 -
Explore the Trendlineâž”
Yujin Kim/Healthcare Dive
TrendlinePayer/provider relationships
As M&A intensifies and companies embrace more holistic and value-based care models, partnerships have become more closely intertwined.
By Healthcare Dive staff -
iStock via Getty Images
How to reform Medicare’s physician fee schedule to reprioritize primary care
America’s primary care chassis is crumbling, and how Medicare pays physicians is partially to blame. Expanding value-based payment arrangements could be the answer, experts say.
By Rebecca Pifer • Sept. 17, 2025 -
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Optum Rx hikes payment floor on brand name drugs for independent pharmacies
The move builds on the major PBM’s pivot to cost-based pricing for pharmacies announced earlier this year.
By Rebecca Pifer • Sept. 17, 2025 -
Kayla Bartkowski via Getty Images
GOP bill extends telehealth flexibilities, sidesteps ACA subsidies
The continuing resolution would preserve virtual care flexibilities through Nov. 21. But it makes no mention of extending more generous financial assistance for people who buy plans on the ACA exchanges.
By Emily Olsen • Sept. 17, 2025 -
Bill Oxford via Getty Images
Doctors slam specialty cuts in 2026 Medicare pay proposal
Major physician groups and specialists commented in droves that regulators missed the mark on the Medicare physician fee schedule for next year.
By Rebecca Pifer • Sept. 16, 2025 -
Dan Zukowski/Healthcare Dive
Democrat governors urge Congress to extend ACA subsidies
Eighteen blue state governors are warning of a looming affordability cliff for millions of Americans if lawmakers allow generous financial assistance to lapse at the end of this year.
By Rebecca Pifer • Sept. 16, 2025 -
Bill Oxford via Getty Images
Medicare prior authorization pilot raises concerns among providers
The additional red tape could save money, but may harm patient access and quality of care. Stakeholders are urging the CMS to increase transparency and hold participants accountable.
By Michael Brady • Sept. 16, 2025 -
yavdat via Getty Images
AMA releases 2026 medical codes
The American Medical Association unveiled new CPT codes on Thursday amid signs that the Trump administration may reduce the lobby’s influence over the medical billing system.
By Rebecca Pifer • Sept. 12, 2025 -
Brandon Bell / Staff via Getty Images
Health benefit cost increases expected to hit 15-year high, Mercer warns
2026 will mark the fourth consecutive year of substantial health benefit cost growth, signaling “mounting pressure on employers’ healthcare budgets.”
By Ginger Christ • Sept. 10, 2025 -
Courtesy of UnitedHealth Group
Early Medicare Advantage stars data bodes well for UnitedHealth
The healthcare behemoth expects to have roughly 78% of its MA enrollees in plans rated four stars or higher, a key cutoff for valuable bonuses in the privatized Medicare program.
By Rebecca Pifer • Sept. 9, 2025 -
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Medicare Advantage penetration doesn’t translate to lower hospital margins: MedPAC
The findings throw cold water on allegations from hospital groups that MA plans contribute to shrinking margins.
By Rebecca Pifer • Sept. 9, 2025 -
Joe Raedle via Getty Images
House Republicans probe CVS for alleged HIPAA violation
In June, CVS sent a mass text to pharmacy customers in Louisiana urging them to contact their representatives to oppose a PBM reform bill. That may have been illegal, two Republican congressmen say.
By Rebecca Pifer • Sept. 8, 2025 -
designer491 via Getty Images
States unprepared to implement Medicaid work requirements: report
Implementing work requirements should be a “multi-year project,” researchers said, but states have just until next year to prepare.
By Susanna Vogel • Sept. 8, 2025 -
Avosb via Getty Images
Aetna, Optum settle ‘dummy codes’ case for $8.4M
The decade-long case alleged that Aetna and Optum Health conspired to pass along administrative costs to patients by disguising them as medical codes.
By Rebecca Pifer • Sept. 8, 2025 -
Permission granted by Elevance Health
Elevance cuts MA footprint, exits standalone Medicare prescription drug plans
Roughly 150,000 individual and group MA members will be affected by the plan exits, as will some 400,000 Part D enrollees.
By Rebecca Pifer • Sept. 5, 2025 -
Joe Raedle via Getty Images
HHS expands access to catastrophic plans ahead of premium pain on ACA exchanges
The move will give more Americans a coverage alternative with low monthly premiums come November’s open enrollment, but could come at the expense of people who remain in standard Affordable Care Act plans.
By Rebecca Pifer • Sept. 4, 2025 -
Courtesy of Medtronic
Renal denervation gets strong backing from cardiologists ahead of Medicare coverage decision
Doctors told the CMS that more patients need access to the procedure, with one calling it the start of a new era in hypertension management.
By Susan Kelly • Sept. 4, 2025 -
Alex Wong via Getty Images
CMS tweaks AHEAD all-payer model for states
The model will now run for one additional year and require providers to assume more downside risk.
By Rebecca Pifer • Sept. 4, 2025 -
iStock via Getty Images
UnitedHealthcare, Humana are gaming Medicare Advantage risk adjustment, analysis finds
The research from the Alliance for Community Health Plans adds to existing evidence that major insurers are unfairly profiting from MA’s risk adjustment system, driving billions of dollars in unnecessary costs.
By Rebecca Pifer • Sept. 3, 2025 -
Foremniakowski via Getty Images
Medicare saved record $2.4B from largest accountable care program last year
ACOs are also improving in quality, according to the CMS data. Still, the Medicare Shared Savings Program has struggled with waning provider buy-in.
By Rebecca Pifer • Sept. 3, 2025 -
Joe Raedle via Getty Images
CVS agrees to pay Massachusetts $12M to settle Medicaid overbilling claims
The retail pharmacy giant has also agreed to annually review its practices to ensure the state’s Medicaid program is getting the lowest possible prices for prescription drugs.
By Rebecca Pifer • Sept. 2, 2025 -
Julia Rendleman via Getty Images
Cigna’s Evernorth invests $3.5B in ex-Walgreens specialty pharmacy
The investment in Shields Health Solutions gives Evernorth greater reach into specialty pharmacy services for providers, which Cigna’s COO has called an “important addressable market expansion opportunity.”
By Rebecca Pifer • Sept. 2, 2025 -
Adene Sanchez via Getty Images
Medicare Advantage plans frequently deny post-acute care for nursing homes, survey finds
The findings build on other research suggesting that MA insurers restrict care more than they should, especially post-acute services.
By Rebecca Pifer • Aug. 28, 2025 -
Tom Brenner via Getty Images
Top healthcare legislation to watch so far this year
Federal lawmakers have proposed dozens of bills targeting core healthcare issues, including 340B, Medicaid, AI and site-neutral payments.
By Healthcare Dive staff • Aug. 28, 2025
