Payer: Page 3
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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 • Sept. 8, 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 -
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 -
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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 • 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 -
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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 • 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 • 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 • Sept. 2, 2025 -
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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 -
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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 • Aug. 28, 2025 -
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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 • 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 • 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 • 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 • 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 • 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 • Aug. 21, 2025 -
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CVS Caremark fined $290M for Medicare fraud
CVS tried and failed to convince the judge to decrease the penalty. The company plans to appeal the ruling.
By Rebecca Pifer • Aug. 20, 2025 -
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Medicare Advantage headwinds dinging member satisfaction: survey
Overall customer satisfaction with MA plans fell 29 points year over year, driven by declining member trust, according to J.D. Power.
By Emily Olsen • Aug. 20, 2025 -
Alamy
Elevance loses Medicare Advantage star ratings suit
The Texas judge’s decision — which picked apart Elevance’s argument on mathematical grounds — is expected to cost Elevance $375 million, though the insurer could still appeal.
By Rebecca Pifer • Aug. 20, 2025 -
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Judge overturns rule limiting broker payments in Medicare Advantage
Reed O’Connor’s ruling is a setback for smaller MA plans — and efforts to curb predatory marketing to seniors.
By Rebecca Pifer • Aug. 20, 2025 -
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Large employers forecast ‘daunting’ 9% hike in healthcare costs next year
Employers surveyed by the Business Group on Health are bracing for the largest annual increase in healthcare costs in more than a decade — a sobering prospect, one expert said.
By Rebecca Pifer • Aug. 19, 2025 -
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Sponsored by ZelisWhy this summer is make-or-break for star ratings
More star ratings changes are coming – and your actions this summer are critical for Stars success.
Aug. 18, 2025
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