Payer: Page 11
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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 -
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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 Parduhn • Sept. 12, 2025 -
Explore the Trendline➔
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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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 Parduhn • 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 Parduhn • Sept. 9, 2025 -
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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 Parduhn • Sept. 8, 2025 -
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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 -
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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 Parduhn • 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 Parduhn • Sept. 5, 2025 -
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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 Parduhn • 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 -
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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 Parduhn • Sept. 4, 2025 -
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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 Parduhn • Sept. 3, 2025 -
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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 Parduhn • Sept. 3, 2025 -
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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 Parduhn • 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 Parduhn • Sept. 2, 2025 -
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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 Parduhn • 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 -
Courtesy of Blue Shield of California
Blue Shield of California names interim CEO to permanent chief executive
Mike Stuart has been the California Blues giant’s interim CEO since March. Now, he’s officially stepping into the role.
By Rebecca Pifer Parduhn • Aug. 27, 2025 -
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Surprise BillingNo Surprises dispute resolution is creating billions of dollars in extra costs, could raise premiums: analysis
Providers are turning to the law’s arbitration process in droves to settle out-of-network claims, one factor fueling spending that could cost consumers down the line.
By Rebecca Pifer Parduhn • Aug. 27, 2025 -
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Johns Hopkins, UnitedHealthcare end contract negotiations after failing to reach agreement
The Baltimore-based system and the major insurer called off contract negotiations, keeping some 60,000 patients out of network.
By Rebecca Pifer Parduhn • Updated Sept. 18, 2025 -
Joe Raedle via Getty Images
Judge stays provisions of Trump administration rule overhauling ACA
A Maryland district judge has paused heightened standards for people verifying their eligibility for subsidies and other key elements of a controversial final rule from July.
By Rebecca Pifer Parduhn • Aug. 25, 2025 -
DC Studio, Adobe Stock
Sponsored by West MonroePrior authorization reform: Turning regulatory pressure into a competitive edge
PA reform: four steps that separate health plan leaders from survivors.
By Dan Howell • Aug. 25, 2025 -
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Judge approves $2.8B Blues settlement with providers
The final settlement wraps up 12 years of litigation over Blue Cross and Blue Shield plans’ alleged collusion to lower reimbursement to U.S. providers.
By Rebecca Pifer Parduhn • Aug. 22, 2025 -
Courtesy of UnitedHealth Group
UnitedHealth forms new ‘public responsibility’ board committee
The committee will oversee areas where UnitedHealth has struggled or faced public scrutiny: underwriting and forecasting, regulatory relationships, reputational matters, and M&A.
By Rebecca Pifer Parduhn • Aug. 21, 2025
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