CMS tweaks ACO REACH to stabilize model

Regulators lowered enrollment minimums for accountable care organizations in the program, which allows providers to form groups to manage care and costs for fee-for-service Medicare enrollees.

By Rebecca Pifer Parduhn • Aug. 15, 2023

Will the Biden administration’s short-term plan rule increase the uninsured rate?

Free-market advocates argue proposed restrictions on short-term plans will leave consumers without coverage. Health policy researchers aren’t so sure.

By Rebecca Pifer Parduhn • Aug. 14, 2023

AdventHealth sues MultiPlan for alleged ‘cartel’ with health insurers to fix prices

The health system alleges providers have lost at least $19 billion per year as a direct result of MultiPlan’s anticompetitive agreements with major payers, including UnitedHealth, Aetna and Elevance.

By Rebecca Pifer Parduhn • Aug. 14, 2023

DOJ hits UnitedHealth, Amedisys with second request over $3.3B deal

The request for more information pushes back the timeline of the merger as regulators take a more active stance in healthcare M&A oversight.

By Rebecca Pifer Parduhn • Aug. 11, 2023

MA bonuses reach record high, with UnitedHealthcare, Humana biggest winners

Star ratings bonuses reached $12.8 billion, according to the KFF, as the Medicare program faces a growing spending crisis.

By Rebecca Pifer Parduhn • Aug. 10, 2023

Hospital prices twice as high for commercial plans than MA when negotiated by same payer, study finds

Large national insurers had higher price ratios than other payers, an analysis in Health Affairs found.

By Emily Olsen • Aug. 9, 2023

Smaller insurers tout progress toward profitability in Q2

Clover notched its first quarterly adjusted EBITDA profit as a public company, while Oscar reached total company profitability for the second quarter in a row. Meanwhile, Bright posted its first quarter ever with positive adjusted EBITDA.

By Rebecca Pifer Parduhn • Aug. 9, 2023

5 takeaways from health insurers’ second-quarter earnings

UnitedHealth, CVS, Elevance and peers sidestepped the worst of medical cost growth in the quarter, but many payers face uncertainty from Medicare Advantage star ratings, GLP-1s and other pressures.

By Rebecca Pifer Parduhn • Aug. 8, 2023

Elevance snags Moody’s exec for new CFO

Current CFO John Gallina is leaving Elevance after almost three decades in various leadership roles, including seven years as CFO.

By Rebecca Pifer Parduhn • Aug. 8, 2023

Texas judge rules in favor of doctors in latest suit over surprise billing process

The decision is expected to increase the number of claims providers file in the independent dispute resolution process, especially for smaller amounts, according to a health lawyer.

By Rebecca Pifer Parduhn • Aug. 7, 2023

Former CMS, BCBS exec steps up as CEO of OptumRx in UnitedHealth leadership shakeup

In a chain reaction of executive moves, Patrick Conway is replacing Heather Cianfrocco as CEO of UnitedHealth’s pharmacy benefit manager.

By Rebecca Pifer Parduhn • Aug. 4, 2023

Health insurers ignore surprise billing decisions, providers allege

Payers didn’t reimburse doctors in more than half of arbitration award cases, according to a survey from clinician group Americans for Fair Health Care.

By Rebecca Pifer Parduhn • Aug. 4, 2023

Kentucky sues major PBMs over rising insulin prices

A string of states and cities have filed recent suits against PBMs and drug manufacturers alleging they work in tandem to raise the cost of insulin.

By Sydney Halleman • Aug. 4, 2023

Cigna checks medical cost growth as Evernorth earnings boosted by GLP-1s

Cigna’s medical costs in the quarter were “well-controlled,” one analyst said, but faced pressure from higher estimated risk-adjustment payments in the ACA individual exchanges.

By Rebecca Pifer Parduhn • Aug. 3, 2023

U.S reaches record low uninsured rate just prior to Medicaid redeterminations

The uninsured rate fell to a record low in March, but Medicaid eligibility checks could reverse that progress, according to experts.

By Susanna Vogel • Aug. 3, 2023

UnitedHealth unit sued by Labor Department over systematic claims denials

The government is alleging plan administrator UMR improperly denied thousands of ER and drug screening claims submitted between 2015 and 2018.

By Susanna Vogel • Aug. 2, 2023

CVS announces restructuring plan after profit falls 37%

CVS also lowered its 2024 earnings outlook, citing cost pressures, and said investors should no longer rely on its 2025 target.

By Rebecca Pifer Parduhn • Aug. 2, 2023

Humana reports lower-than-feared medical costs, raises MA membership growth outlook

Humana’s stock rose following the earnings, which — along with comments from other payers — suggest the uptick in outpatient care flagged earlier in the quarter is moderating.

By Rebecca Pifer Parduhn • Aug. 2, 2023

CVS to lay off 5K employees amid cost pressures

The job cuts come as CVS faces hefty integration costs from recent M&A, including its $10.6 billion buy of Oak Street and $8 billion acquisition of Signify.

By Rebecca Pifer Parduhn • Aug. 1, 2023

Elevance rebrands Amerigroup segment as Wellpoint

The return of the Wellpoint brand for Amerigroup, which covers Medicaid and Medicare members, is the payer's latest corporate reinvention.

By Rebecca Pifer Parduhn • Aug. 1, 2023

Hospital, payer lobbies urge CMS to reconsider ‘conflicting’ prior authorization standards

The groups, normally at odds, have found a source of agreement in proposed rules meant to standardize data exchange processes.

By Brian T. Horowitz • July 31, 2023

CMS releases April Medicaid unwinding data. Total disenrollments top 3.8M

The highly-anticipated data pegging the nation’s procedural disenrollment rate at 80% is higher than more recent estimates.

By Rebecca Pifer Parduhn • July 28, 2023

Centene’s 2024 outlook hampered by Medicaid redeterminations

The payer lost 262,700 Medicaid members in the second quarter, dropping its total Medicaid lives to just over 16 million.

By Rebecca Pifer Parduhn • July 28, 2023

Nevada to shut down Friday Health Plans

State regulators will liquidate the failing insurtech, leaving about 3,000 enrollees to look for new coverage.

By Emily Olsen • July 27, 2023

Molina reports Medicaid redeterminations proceeding as expected

Despite concerns about high early levels of disenrollments, the payer lost 93,000 Medicaid members during the second quarter — well within forecasts, CEO Joe Zubretsky said.

By Rebecca Pifer Parduhn • July 27, 2023