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Provider Wins In NSA Disputes Becoming Outlandish

More evidence that the terribly flawed No Surprises Act dispute process is getting more outlandish, yet lawmakers lack the courage to fix it. Meanwhile, awards continue to drive costs in the system in two ways – the sheer cost of the awards and driving up price points in the system overall.

A new federal analysis says disputes rose almost 75% to more than 2.5 million from 2024 to 2025. CMS originally projected just 17,000 cases a year when the law passed. Providers won 83.6% of disputes in Q4 2025, roughly consistent since 2023.

Provider groups of course claim the dollars awarded are merited. Health plans say providers are abusing the system and the process is incredibly slanted to providers.  A long-delayed reform rule is likely destined to do little to change the paradigm.

It is also true that a small subset of certain specialists are raking in the highest awards. Surgical and neurology procedures have resulted in a huge increase in reimbursements. Insurers paid a median award equal to 2,585% of the qualifying payment amount for neurology procedures in Q4, up from 1,262% during Q4 2023.

Arbitration processes are meant to be a 50-50 proposition – not 84-16. And to show how biased the process really is, plans offering five times the qualifying payment amount still lose about 75% of the time.

#nsa #nosurprisesact #transparency #providers #healthplans

https://www.modernhealthcare.com/providers/mh-no-surprises-act-billing-disputes-idr

— Marc S. Ryan

JD Power Finds Decline in MA Satisfaction

A new study by JD Power finds that satisfaction with Medicare Advantage (MA) plans has declined for a second year. Overall satisfaction was 611 on a 1,000-point scale, down 12 points from the 2025 report and 41 points from 2024. 

The study identified declines across the member experience, with the steepest declines over two years in how much the plan is saving time and money (down 51 points); level of trust (down 49 points); and coverage options to meet individuals’ needs (down by 47 points).

The decline is obviously related to major cutbacks in access and benefits as the industry grapples with realignment and margin recovery.

In other news, Modern Healthcare covers the Q2 financial recovery by plans and outlook for continued improvement. I covered this topic in a blog here: https://www.healthcarelabyrinth.com/are-insurers-turning-the-financial-corner-yes-but-there-is-more-work-to-be-done/ .

Additional article: https://www.fiercehealthcare.com/payers/jd-power-member-satisfaction-medicare-advantage-plans-continues-slide

#medicareadvantage #margins

https://www.modernhealthcare.com/insurance/mh-unitedhealth-humana-aetna-medicare-advantage-2027

Trump Reining In Medicaid Waivers, Further Complicating State Medicaid Budgets

The Centers for Medicare and Medicaid Services (CMS) is paring back on 1115 research and demonstration waivers. Critics say this could increase enrollee churn, undercut finances for providers, and impact innovation. States are already grappling with work requirements as well as reductions to provider taxes used to fund the state share or contribution.

The administration argues that the Medicaid footprint has grown considerably over the years, funded inappropriate areas, and has not lived up to budget neutrality.  The administration has defunded social needs waivers and will not renew continuous coverage enrollment.  

CMS has informally notified Arkansas that its private option Medicaid expansion under the Affordable Care Act of 2010 will not be renewed. Arkansas is seeking a two-year extension after CMS rejected its five-year renewal. It impacts 200,000 enrollees.

In other news, California’s Medicaid program, Medi-Cal, will reduce its asset limits 84% in July 2027. In 2022, California moved the asset limit from $2,000 to a ridiculous $130,000 for individuals and wanted to drop the asset test altogether at one time, which was approved by the Biden administration. But due to budget difficulties, the asset limit now will drop to $21,000 for singles.

Additional article: https://www.beckerspayer.com/payer/medicaid/medi-cal-plans-brace-for-devastating-asset-limit-crunch/

#medicaid #waivers #coverage

https://www.modernhealthcare.com/politics-regulation/mh-cms-medicaid-1115-waiver-states

KFF Finds $60B At Risk With Directed Payment Reforms

Healthcare policy group KFF finds that an estimated $60 billion in federal Medicaid spending in 37 states (including the District of Columbia) would likely exceed new federal limits on state directed payments for hospital services once fully implemented under the One Big Beautiful Bill Act (OBBBA).

The eight states with the biggest potential reductions in Medicaid payments to hospitals are: California ($7.4 billion), Illinois ($4.0 billion), Kentucky ($3.9 billion), Texas ($3.5 billion), North Carolina ($3.4 billion), Louisiana ($3.3 billion), Arizona ($3.0 billion) and Michigan ($2.6 billion). This accounts for about half of the total.

While controversial, there is little doubt in my mind that intergovernmental transfers, provider taxes, and state directed payments have been abused by many states and some reforms are needed.

Additional article: https://www.kff.org/medicaid/analysis-at-least-37-states-have-medicaid-state-directed-payments-for-hospital-services-that-could-be-reduced-by-the-2025-reconciliation-law-limits/

#medicaid #obbba #healthcare #coverage

https://www.kff.org/medicaid/at-least-37-states-have-medicaid-state-directed-payments-for-hospital-services-that-could-be-reduced-by-the-2025-reconciliation-law-limits/

Aetna’s VBC Approach Paying Dividends

CVS Health’s Aetna health plan is seeing its value-based care (VBC) investments paying off in terms of preventive care metrics and cost savings.

The insurer looked at 20 different measures for individuals in its Medicare Advantage (MA) plans between VBC models and fee-for-service (FFS) reimbursement. It determined that VBC arrangements resulted in better results across 17 measures. About 43% more members controlled their HbA1C and 34% had controlled blood pressure. About 20% more patients were screened for colorectal cancer and there were 7% fewer hospitalizations.

VBC providers generated $315 million in savings during plan year 2023, 2.6% higher than FFS providers. VBC risk arrangements vary. Providers in two-sided risk models had the strongest performance across multiple measures in the report. Aetna says that, given apprehension and differences in maturity in the provider market, it enters into various levels of VBC models with providers.

Report: https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/insights/aetna-medicare-vbc-whitepaper.pdf

#healthplans #vbc #valuebasedcare

https://www.fiercehealthcare.com/payers/look-where-aetna-seeing-value-based-care-success-medicare-advantage

Parts of No Surprises QPA Rule Struck

A federal appeals court has ruled that the government’s methodology for calculating the qualifying payment amount (QPA) within the No Surprises Act’s arbitration process is partly unlawful. This could lead insurers to have to recalculate such future offers at higher rates. The court found that inclusion of so-called “ghost rates” in the calculation and excluding bonus and incentive payments did not meet the law.

The law heavily favors providers already. The move could mean higher benchmark payments in general over time. But it could also move the last best offers of plans up in the arbitration process. Would that sway some arbitrators to award to plans? So far, the awards are 85% in favor of plans and at payment amounts that are well higher than before the law went into effect. It is driving higher prices overall.

Additional articles: https://www.beckershospitalreview.com/legal-regulatory-issues/5th-circuit-strikes-down-parts-of-no-surprises-qpa-rule-rejects-air-ambulance-challenge/ and https://www.beckerspayer.com/policy-updates/the-never-ending-no-surprises-saga/

(Some articles may require a subscription.)

#nosurprisesact #providers #healthplans #transparency

https://www.modernhealthcare.com/legal/mh-no-surprises-act-payment-appeals-court

Trump Administration Defends Exchange Paring

The Trump administration went on the offensive today arguing that studies prove the reduction in Exchange enrollment in 2026 was the result of fraud control efforts enacted during the last few years. It said the sharp rise in premiums was not the cause. Policy experts dispute this and argue that tougher enrollment processes and enhanced premium subsidy expiration led to a surge in premiums and enrollment declines.

Enrollment in Exchange plans fell by nearly 3 million nationwide this year to about 19.2 million. The Trump administration says 2.9 million people were removed through fraud initiatives. More are expected to cancel coverage throughout the year due to premium affordability issues.

I have a blog running Thursday on this topic. Stay tuned. But a hint on where I stand – the truth is always somewhere in the middle.

#exchange #enrollment #coverage

https://www.fiercehealthcare.com/regulatory/kennedy-oz-contend-fraud-crackdown-not-skyrocketing-prices-led-millions-leave-obamacare

Many Plans Still Showing Losses

Despite a reasonable recovery among the national health players in Q2 2026, HealthScape Advisors, part of Chartis, says health plans remain under significant financial pressure. Its annual look at health plans’ financial performance finds that plans posting an operating loss increased over the past several years. In 2023, 54% of health plans reported an operating loss, and that grew to 70% in 2024. And in 2025, that rose again to 73%.

HealthScape says operating losses are concentrated among regional plans and Blues plans, with 72% of regional insurers and 83% of Blues reporting one in 2025. Fourteen percent of national payers reported an operating loss in 2023 and 2024, but the rate jumped to 43% in 2025.

Read my blog last week on the national players here: https://www.healthcarelabyrinth.com/are-insurers-turning-the-financial-corner-yes-but-there-is-more-work-to-be-done/

#healthplans #margins

https://www.fiercehealthcare.com/payers/number-health-plans-reporting-operating-losses-growing-report

340B Bill Would Hinder Administration’s Reforms

Another bill with bipartisan Senate support has been introduced to stop the administration from extending a rebate pilot it plans to launch that would convert 340B upfront discounts to retrospective rebates. 

The bill would establish an independent, third-party data clearinghouse to address Big Pharma’s concerns that discounts are being diverted and duplicated by qualifying hospitals and other participants. The entity would coordinate 340B transaction data between parties and oversee any issues.

#340b #drugpricing #branddrugmakers #hospitals

https://www.fiercehealthcare.com/regulatory/new-bipartisan-340b-reform-bill-curbs-hhs-rebate-pilot

Oscar, Clover Have Good Financial Results

Exchange-dominant Oscar Health reported strong Q2 results, with a profit of $362 million compared with a loss of $228.4 million a year ago. The company saw record profitability in 1H 2026, generating $1.1 billion in earnings from operations and $1 billion in net income.

Clover Health’s Medicare Advantage (MA) membership grew 48% year-over-year in Q2 to 157,309 members. The company posted $153 million in profit, up 54% from Q2 2025, and revenue of $743 million, up 56% from Q2 2025. It was also buoyed by its Star lawsuit win.

Additional article: https://www.fiercehealthcare.com/finance/oscar-health-boosts-2026-earnings-outlook-after-record-profitability-during-first-half-year

#healthplans #margin

https://www.fiercehealthcare.com/finance/clover-health-reaffirms-ai-commitments-discusses-star-rating-amid-strong-q2-performance