Payer
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HHS watchdog says it’s targeting Medicaid, Medicare Advantage fraud
The HHS Office of Inspector General said it had kicked over 1,200 people and entities off federal programs between October and March as the Trump administration ratchets up oversight into what it says is rampant fraud in healthcare.
By Sydney Halleman • July 13, 2026 -
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‘The system is undeniably broken’: More insurers sue CMS over Medicare Advantage stars
SCAN Health Plan and Alignment Healthcare both filed lawsuits against the CMS last week after regulators refused to recalculate industry-wide MA scores using the same methodology as for Clover Health.
By Rebecca Pifer Parduhn • July 13, 2026 -
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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 -
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Soon-to-expire ACO REACH generates more savings for Medicare
The model, which is set to sunset at the end of this year, generated $988 million in savings for Medicare in 2024, according to new CMS data. That’s up from almost $695 million in savings from the year prior.
By Rebecca Pifer Parduhn • July 13, 2026 -
Retrieved from Memorial Hermann on July 10, 2026
Memorial Hermann exits commercial insurance business
The Houston-based nonprofit is the latest integrated system to throw in the towel on some of its insurance plans amid a tough cost and policy environment.
By Rebecca Pifer Parduhn • July 10, 2026 -
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Bankrupt Omnicare reaches $440M deal with DOJ in fraud case
The settlement could be the end of a long legal saga for Omnicare, which filed for bankruptcy last year after a judge ordered the company to pay nearly $950 million for fraudulently billing government health programs.
By Emily Olsen • July 10, 2026 -
Permission granted by The Economic Club of Washington, DC/Gary Cameron
CVS CEO says Aetna has a handle on medical costs in advance of Q2 earnings
David Joyner’s assurances, which come about a month before CVS is scheduled to report its second quarter results, will likely be welcomed by investors wary after a difficult few years for insurers.
By Rebecca Pifer Parduhn • July 9, 2026 -
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Whistleblower lawsuit accuses Alignment of accounting fraud
A former executive is claiming that the MA insurer recorded millions of dollars as capital expenditures that should have been operating expenses, inflating its value. Alignment strongly denied the allegations.
By Rebecca Pifer Parduhn • July 9, 2026 -
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ACA premiums set to spike again in 2027
Insurers are proposing a median premium increase of 14% for 2027, according to KFF, suggesting another year of double-digit premium hikes as policy upheaval and rising costs continue to roil the marketplaces.
By Emily Olsen • July 8, 2026 -
Alamy
Centene exits Arkansas Medicaid expansion program, citing funding challenges
ARHOME represents a small portion of Centene’s overall membership and premiums. But the exit shows how insurers are rejigging their businesses in advance of Medicaid work requirements, one analyst said.
By Rebecca Pifer Parduhn • July 8, 2026 -
Courtesy of UnitedHealth Group
External audit of UnitedHealth senior home visits finds most diagnoses supported by medical data
Almost 97% of diagnoses found in HouseCalls visits were backed up by patients’ medical records, vindicating the program’s integrity, UnitedHealth said.
By Rebecca Pifer Parduhn • July 7, 2026 -
Permission granted by RAAPID
Sponsored by RAAPID INCKLAS Emerging Company Spotlight: Enhancing risk adjustment coding defensibility through neuro-symbolic AI solutions
See the grades RAAPID's customers gave in the 2026 KLAS Emerging Company Spotlight.
By Chris Lally, VP of Operations, RAAPID • July 6, 2026 -
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Elevance sues CMS after Medicare Advantage stars recalculation
Regulators recalculated plans’ quality scores last month after losing a lawsuit to Clover Health. But they used a different methodology for Clover than its peers, causing Elevance to lose out on $115 million, the insurer told a court.
By Rebecca Pifer Parduhn • July 2, 2026 -
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Medicare Advantage bonuses will exceed $13B this year, KFF finds
Medicare is spending more on quality bonuses despite fewer enrollees in eligible plans, the health policy research group said — a concerning trend putting more stress on Medicare’s coffers that could amplify calls for reform.
By Rebecca Pifer Parduhn • July 2, 2026 -
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Nearly 4M Medicare beneficiaries could access GLP-1s for weight loss under new program: analysis
Millions of people could meet criteria to receive GLP-1s, which could cost Medicare billions of dollars, according to a report by KFF.
By Emily Olsen • July 1, 2026 -
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Court dismisses PBMs’ lawsuit against FTC following insulin settlements
Express Scripts, Caremark and Optum Rx sued the FTC after the agency accused them of driving up the cost of insulin. But the countersuit is being put to bed now that the PBMs are settling with regulators.
By Rebecca Pifer Parduhn • July 1, 2026 -
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States sue Trump administration over Medicaid work requirements rule
Twenty-six states are seeking to overturn some of the regulation released by the CMS this month that outlined Medicaid work requirements — and asking the court to pause implementation for the time being.
By Sydney Halleman • June 30, 2026 -
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ACA enrollment declines by nearly 3M
ACA plan enrollment continues to shrink following the lapse of more generous subsidies last year, according to new federal data.
By Emily Olsen • June 29, 2026 -
Rebecca Pifer Parduhn/Healthcare Dive
State Medicaid directors defend program integrity as Dems cry foul in House hearing
The Trump administration says its war on fraud applies to the entire country. But only blue states have had their Medicaid funding threatened or deferred, Democrats argued in a House subcommittee hearing Thursday.
By Rebecca Pifer Parduhn • June 26, 2026 -
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US health spending spikes to $5.7T in 2025, though growth should moderate, CMS finds
Utilization — not cost growth — continues to accelerate spending, government actuaries said. Rising prescription drug spending, including on GLP-1s, is especially acute.
By Rebecca Pifer Parduhn • June 24, 2026 -
Samantha Liss/Healthcare Dive
Centene adds JPMorgan veteran to board
Incoming board member Lauren Tyler has more than 30 years of leadership experience in the finance world, which could help Centene navigate the challenging operating environment facing insurers.
By Rebecca Pifer Parduhn • June 24, 2026 -
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Florida launches probe into CVS for alleged anticompetitive pharmacy practices
The investigation by Florida’s attorney general comes as states look to check pharmacy benefit managers for allegedly driving up drug costs.
By Emily Olsen • June 24, 2026 -
Permission granted by CVS Caremark
Sponsored by CVS CaremarkDisaggregation vs. integration: Why an integrated pharmacy benefits strategy is the right choice
Health plans need to understand why integration is still the most impactful option for their pharmacy benefits model.
By Ed DeVaney, EVP and President, CVS Caremark • June 22, 2026 -
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PCMA sues to exempt PBMs from Illinois drug law
It’s the second major lawsuit the pharmacy benefit manager lobby has filed against a state law reforming the industry in recent weeks.
By Rebecca Pifer Parduhn • June 18, 2026 -
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Employers plan to shift more health costs to employees
Employers are considering raising premiums and increasing other forms of cost sharing as they grapple with stubbornly rising health costs, according to a new survey from Mercer.
By Sydney Halleman • June 18, 2026 -
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CMS recalculates Medicare Advantage stars after Clover lawsuit loss, but not a freebie for plans
Regulators are locking in new 2026 stars for plans if they’re higher under the new methodology. But the recalculation basically results in no change to average star ratings unless you’re Clover, analysts say.
By Rebecca Pifer Parduhn • June 18, 2026
