Payer


  • Surprise Billing

    CMS’ first No Surprises audit targets Aetna, finds some noncompliance

    The findings are a “big deal,” according to one expert, as CVS’ health insurer didn’t follow some “major requirements that are essential to ensuring that the IDR process runs smoothly.”

    By July 12, 2024
  • A picture of the exterior of the US Department of Health and Human Services. In front of the building is a black sign designating the building's name.
    Image attribution tooltip
    Alex Wong via Getty Images
    Image attribution tooltip

    CMS proposes 2.9% cut to physician pay for 2025

    Regulators said Medicare’s budget neutrality requirement is to blame for the reduction, which was quickly decried by provider groups. However, it’s likely Congress will step in to mitigate the drop.

    By July 11, 2024
  • Dietitian writing a diet plan, view from above on the table with different healthy products and drawings on the topic of healthy eating. Explore the Trendline
    Image attribution tooltip
    RossHelen via Getty Images
    Image attribution tooltip
    Trendline

    Social determinants of health

    The focus on social determinants of health has only increased because of the impacts of the pandemic, with payers and providers trying to new ways to address the issues.

    By Healthcare Dive staff
  • Concept image of insulin aspart with fake labeling
    Image attribution tooltip
    Samara Heisz via Getty Images
    Image attribution tooltip

    Federal Trade Commission to sue three largest PBMs: WSJ

    Antitrust regulators are poised to file suit against CVS Caremark, Express Scripts and Optum Rx over how they negotiate discounts for drugs, including insulin, according to the report.

    By July 10, 2024
  • A picture of the exterior of the US Department of Health and Human Services. In front of the building is a black sign designating the building's name.
    Image attribution tooltip
    Alex Wong via Getty Images
    Image attribution tooltip

    Judge pauses CMS rule capping compensation for Medicare Advantage brokers

    Texas Judge Reed O’Connor’s decision suggests he could overturn at least part of the rule, which is meant to curb predatory plan marketing to seniors.

    By July 10, 2024
  • The HHS in DC
    Image attribution tooltip
    Alex Wong / Staff via Getty Images
    Image attribution tooltip

    Medicare proposes 2.6% bump to hospital outpatient pay next year

    The sweeping payment rule also solidifies continuous eligibility requirements for children in Medicaid and CHIP, and holds hospitals to higher obstetric care delivery standards in a bid to improve maternal mortality.

    By July 10, 2024
  • A picture of the exterior of the US Department of Health and Human Services. In front of the building is a black sign designating the building's name.
    Image attribution tooltip
    Alex Wong via Getty Images
    Image attribution tooltip

    CMS revised Medicare Advantage star ratings. Here’s which payers benefited.

    More than 60 Medicare Advantage health plans from 40 insurers have received a higher star rating for 2024, according to a Healthcare Dive analysis.

    By July 9, 2024
  • ftc federal trade commission
    Image attribution tooltip
    stock via Getty Images
    Image attribution tooltip

    FTC slams pharmacy benefit managers in first report from ongoing investigation

    On Tuesday, regulators updated the public on their almost three-year-old inquiry into PBMs’ anticompetitive business practices. The report is not positive for the drug middlemen, which immediately criticized it as one-sided.

    By July 9, 2024
  • A cropped picture of a person sitting on their computer with a laptop.
    Image attribution tooltip
    vgajic via Getty Images
    Image attribution tooltip
    Opinion

    Mental health benefits at work are getting better. Here’s how we can go further.

    More employers than ever are focusing on mental health benefits. Congress must invest more and act soon to reauthorize telehealth extensions before it’s too late, argues the director of health policy at the U.S. Chamber of Commerce.

    By Anna Vredenburgh • July 3, 2024
  • A picture of a form that says 'Medicaid eligibility'
    Image attribution tooltip
    designer491 via Getty Images
    Image attribution tooltip
    Medicaid redeterminations

    1 in 8 enrollees exited Medicaid during redeterminations in 4 Southern states: study

    The survey, which included low-income people in Arkansas, Kentucky, Louisiana and Texas, found about half of those who were no longer enrolled in Medicaid were uninsured in late 2023.

    By July 3, 2024
  • UnitedHealth Group office
    Image attribution tooltip
    Courtesy of UnitedHealth Group
    Image attribution tooltip

    UnitedHealth, Amedisys agree to sell clinics to get merger across finish line

    The divestiture will only go through if UnitedHealth and Amedisys complete their merger, which was announced last summer but has been held up amid scrutiny from the Department of Justice.

    By July 2, 2024
  • UnitedHealth Group office
    Image attribution tooltip
    Courtesy of UnitedHealth Group
    Image attribution tooltip

    Optum Rx reaches $20M settlement with Justice Department over opioid prescribing

    The UnitedHealth pharmacy benefit manager did not have to admit guilt as part of the settlement, which amounts to a minuscule fraction of its annual revenue.

    By June 28, 2024
  • A picture of an overturned prescription pill bottle.
    Image attribution tooltip
    Matthew Lloyd via Getty Images
    Image attribution tooltip

    Arkansas sues Optum, Express Scripts over role in opioid epidemic

    Pharmacy benefit managers have largely avoided the brunt of public blame for the deadly opioid crisis. Arkansas’ lawsuit brings the drug middlemen back to the forefront of the controversy.

    By June 25, 2024
  • A gavel rests on a pile of money wrapped with a stethoscope.
    Image attribution tooltip
    yavdat via Getty Images
    Image attribution tooltip

    Appeals court upholds ACA’s preventive services mandate, but opens door to future challenges

    The Fifth Circuit Court of Appeals’ decision Friday is a win for the upwards of 150 million people that receive health insurance through their employers. However, it paves the way for future lawsuits from opponents of the ACA.

    By June 24, 2024
  • A picture of a form that says 'Medicaid eligibility'
    Image attribution tooltip
    designer491 via Getty Images
    Image attribution tooltip

    States using unwinding lessons to improve Medicaid: KFF

    Medicaid unwinding has been less than perfect. However, the process has helped states expand Medicaid eligibility to more people and streamline enrollment and outreach, according to a new survey.

    By June 21, 2024
  • A stethoscope rests on a medical insurance claim form.
    Image attribution tooltip
    iStock / Getty Images Plus via Getty Images
    Image attribution tooltip

    Uninsured rate expected to hit 8.9% over next decade, CBO finds

    New government projections chart a rise in the nation’s uninsured rate as policies that swelled healthcare coverage during the coronavirus pandemic expire.

    By June 18, 2024
  • Amazon Pharmacy
    Image attribution tooltip
    Courtesy of Amazon
    Image attribution tooltip

    Amazon expands drug subscription program to Medicare members

    RxPass is now available to more than 50 million Medicare members after Amazon brought it into compliance with the program’s regulatory standards.

    By June 18, 2024
  • A stethoscope rests on a pile of $100 bills.
    Image attribution tooltip
    Foremniakowski via Getty Images
    Image attribution tooltip
    Change Healthcare cyberattack

    Biden administration gives providers grace period to open surprise billing arbitration

    Because of the cyberattack on Change Healthcare earlier this year, providers say they’re having difficultly getting the necessary information from plans required to kick off the dispute resolution process.

    By June 17, 2024
  • Congressmen Brendan Boyle and Jodey Arrington lean toward one another while having a seated discussion.
    Image attribution tooltip
    Anna Moneymaker via Getty Images
    Image attribution tooltip

    Lawmakers promise to stop kicking the can on Medicare solvency

    The House Budget Committee met Thursday and said they’d take action to restore Medicare’s financial footing, though the hearing was light on specifics.

    By June 14, 2024
  • A picture of the exterior of the US Department of Health and Human Services. In front of the building is a black sign designating the building's name.
    Image attribution tooltip
    Alex Wong via Getty Images
    Image attribution tooltip

    CMMI’s savings record sparks concern among lawmakers

    Republicans at a House subcommittee hearing chided the innovation center for increasing federal spending, even as CMMI’s director said each tested model has resulted in valuable learnings.

    By June 14, 2024
  • A picture of the exterior of the US Department of Health and Human Services. In front of the building is a black sign designating the building's name.
    Image attribution tooltip
    Alex Wong via Getty Images
    Image attribution tooltip

    CMS recalculates Medicare Advantage star ratings in major win for insurers

    The redo comes after regulators lost two court cases over the methodology used to determine 2024’s quality ratings and should result in hundreds of millions of dollars in additional bonuses to plans.

    By June 14, 2024
  • A woman with brown hair clipped up, wearing a pink shirt, bends forward on an exercise bike at a hospital, exhausted.
    Image attribution tooltip
    Marco Di Lauro via Getty Images
    Image attribution tooltip

    Cardiovascular conditions now the second-highest reimbursement category, Sun Life says

    Cost of cardiovascular conditions is up 33% — “higher than we would expect given medical inflation,” the insurance provider said.

    By Emilie Shumway • June 13, 2024
  • A stethoscope rests on a pile of $100 bills.
    Image attribution tooltip
    Foremniakowski via Getty Images
    Image attribution tooltip

    National health spending reached $4.8T last year, CMS actuaries estimate

    More Americans had insurance in 2023 than at any other time in the nation’s history, spurring medical utilization and accelerating healthcare spending faster than growth in the overall economy, according to government projections.

    By June 12, 2024
  • A man exits the front of the U.S. Capitol at dawn.
    Image attribution tooltip
    Win McNamee via Getty Images
    Image attribution tooltip

    MACPAC wants Congress to force states to disclose Medicaid financing streams

    The influential advisory group has been lobbying the federal government to collect more detailed information on how states loop providers into funding Medicaid for almost a decade.

    By June 12, 2024
  • Elevance headquarters is a large white and brown building surrounding a grassy quad.
    Image attribution tooltip
    Permission granted by Elevance Health
    Image attribution tooltip

    Elevance wins star ratings lawsuit (sort of)

    Friday’s district court ruling is the latest suggesting the CMS might have to recalculate every MA plan’s star rating score due to an administrative oversight.

    By June 11, 2024
  • Doctor conversing with tablet to elderly patient.
    Image attribution tooltip

    iStock / Fly View Productions

    Image attribution tooltip
    Sponsored by Veradigm

    3 ways value-based care is transforming American healthcare

    This transition to value-based care is transforming the healthcare system. Medical practices can expect many benefits from this transformation—but only after fully embracing the shift.

    By Amanda Cohen, MPH • June 10, 2024