Microsoft, Blue Shield partner to develop integrated data hub

The hub, which the companies are calling “The Blue Shield Experience Cube,” will create an integrated digital health record as its first use case.

By Brian T. Horowitz • July 27, 2023

Cleveland sues major PBMs, drug manufacturers over rising insulin prices

The suit argues that PBMs, including CVS Caremark, Express Scripts and OptumRx, use their market power to drive up the cost of insulin for Cleveland residents — approximately 17% of whom are diabetic. 

By Sydney Halleman • July 26, 2023

Biden administration cracks down on payers over mental health coverage

A new proposed rule from the HHS and Treasury and Labor departments would require health insurers to analyze patient outcomes to ensure their benefits are administered equally.

By Rebecca Pifer Parduhn • July 25, 2023

Cigna sued over algorithm allegedly used to deny claims

The lawsuit filed in a California district court argues the health insurer used the technology to “deny payment in batches of hundreds or thousands at a time,” violating state law.

By Rebecca Pifer Parduhn • July 25, 2023

ChenMed taps UnitedHealthcare veteran as new president

Family members at value-based medical group ChenMed are stepping down from leadership roles.

By Rebecca Pifer Parduhn • July 24, 2023

PE ownership worsens quality, raises costs, according to BMJ review

The analysis comes as private equity investments in healthcare soar and regulators look to crack down on roll-up acquisitions.

By Sydney Halleman • July 24, 2023

New antitrust merger guidelines could have significant chilling effect on healthcare deals

Regulators have historically struggled to make a case against complex and non-traditional tie-ups. That could change with the new guidelines.

By Rebecca Pifer Parduhn • July 21, 2023

Prior authorization denials could limit access in Medicaid managed care, OIG reports

Medicaid managed care organizations denied one out of every eight requests for prior authorization in 2019, and most states don’t regularly monitor if denials are appropriate, the HHS’ Office of the Inspector General found.

By Emily Olsen • July 20, 2023

CMS pausing Medicaid redeterminations in states noncompliant with renewal requirements

The Biden administration is cracking down on states in an effort to curb rampant procedural disenrollments from the safety-net program.

By Rebecca Pifer Parduhn • July 20, 2023

Elevance curbs elevated medical costs, raises 2023 forecast

Although it’s still early in the redeterminations process, Elevance is seeing “encouraging” signs that many Medicaid members who lose coverage are transitioning onto ACA plans, according to its CFO.

By Rebecca Pifer Parduhn • July 19, 2023

Patients and physicians pay the consequences for health plan delays

The chief medical officer at the Alliance for Patient Access argues for reforms to reduce burdens associated with prior authorization.

By David Charles • July 19, 2023

Returned UnitedHealth executive to lead Optum Health after stint at CVS

Amar Desai will become CEO of Optum’s care delivery organization after returning to UnitedHealth Group from CVS Health this spring.

By Emily Olsen • July 19, 2023

Colorado to shut down failing Friday Health Plans

State regulators had initially hoped the insurtech could operate for the rest of the year, but Colorado’s insurance division became concerned about Friday’s longevity after placing the insurer into rehabilitation.

By Emily Olsen • July 18, 2023

UnitedHealth beats Q2 expectations, despite medical cost growth fears

Rising outpatient utilization among seniors that spooked investors earlier in the quarter left the payer’s bottom line largely unscathed.

By Rebecca Pifer Parduhn • July 14, 2023

Kraft Heinz sues Aetna, says insurer breached ERISA fiduciary duties

Aetna wrongly retained millions in undisclosed fees and paid provider claims “that should have never been paid,” according to the lawsuit filed in a Texas federal court.

By Ryan Golden • July 13, 2023

States’ varying approaches complicate effort to determine impact of Medicaid redeterminations

Millions of people have been disenrolled from Medicaid, but it’s too early to get a full picture of redeterminations’ effect on vulnerable Americans, experts say.

By Emily Olsen • July 13, 2023

Humana, Elevance, Centene downgraded days before second-quarter earnings kickoff

J.P. Morgan and Wolfe Research analysts cited uncertainty and pricing concerns in Medicare Advantage in addition to cost pressures in the commercial market when downgrading major U.S. payers.

By Rebecca Pifer Parduhn • July 13, 2023

CMS faces poor data quality in payment model health equity push

Variable race and ethnicity data is making it difficult to determine whether CMS Innovation Center models are reaching, enrolling and helping underserved beneficiaries, according to a new white paper from the agency.

By Rebecca Pifer Parduhn • July 12, 2023

CVS Caremark, GoodRx partner on automatic drug discounts for commercially insured

The program will be a source of revenue for GoodRx, and might also open a new fee stream for CVS’ pharmacy benefit manager as the drug middlemen face increased scrutiny for complex pricing models.

By Rebecca Pifer Parduhn • July 12, 2023

CMS to return $9B to 340B hospitals under new plan

Hospital groups said the proposed rule is an important step toward restitution for years of 340B underpayments, but they criticized regulators for proposed rate decreases and a lack of additional interest payments.

By Rebecca Pifer Parduhn • July 10, 2023

Home health industry group sues CMS, HHS over payment cuts

The National Association for Home Care and Hospice said regulators used “an illogical and invalid methodology” in a new payment model.

By Emily Olsen • July 7, 2023

Biden admin rolls back Trump-era expansion of short-term health plans

The proposed rule released Friday would limit short-term plan duration to up to four months. Stakeholders have been waiting for President Joe Biden to restrict access to the bare-bones coverage since he assumed office.

By Rebecca Pifer Parduhn • July 7, 2023

FDA grants Eisai’s Leqembi full approval, opening door to wider use of Alzheimer’s drug

The broader approval is expected to push insurers, namely Medicare, to increase coverage of amyloid-targeting therapies.

By Jacob Bell • July 6, 2023

MA beneficiaries more socioeconomically disadvantaged than FFS enrollees, report finds

People who enroll in privately-run MA plans are more likely to be non-white and have lower incomes, according to a white paper from Inovalon and Harvard Medical School.

By Emily Olsen • July 6, 2023

Medicare Advantage’s quality bonus program needs reform, Urban Institute argues

The QBP is a significant source of revenue for MA insurers, but generally doesn’t translate to higher quality care for beneficiaries, according to the nonprofit’s new report.

By Rebecca Pifer Parduhn • July 6, 2023