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United Probe Expansive

The U.S. Justice Department’s (DOJ) criminal division investigation into UnitedHealth Group has been bigger from the start or has expanded. Latest reports suggest that the company is under investigation into both how it reimburses its owned doctors as well as its pharmacy benefit’s manager’s (PBM — OptumRx) business and billing practices. Previously, it was reported the DOJ was investigating alleged Medicare Advantage (MA) risk adjustment fraud.

In the past, I have talked about how federal regulators might go after vertical integration in the healthcare industry and United is the biggest example. Vertically integrated companies are alleged to unfairly inflate price/cost and skirt the minimum medical loss ratio (MLR) rules by having non-arm’s-length agreements with their related companies to keep revenue and margin within the overall enterprise. Could the PBM and physician investigations be touching this concept? It could also be the case that the incentives given owned doctors as well as other pricing and relationships by the PBM violate fraud and other laws.

Additional articles: https://www.modernhealthcare.com/insurance/mh-doj-unitedhealth-optum-rx-medicare-billing/ and https://www.fiercehealthcare.com/payers/wsj-report-doj-interviewing-former-employees-about-medicare-billing-practices-unitedhealth

#fwa #unitedhealthcare #medicareadvantage #doj #antitrust

https://www.bloomberg.com/news/articles/2025-08-26/unitedhealth-ongoing-criminal-probe-is-broader-than-medicare?accessToken=eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJzb3VyY2UiOiJTdWJzY3JpYmVyR2lmdGVkQXJ0aWNsZSIsImlhdCI6MTc1NjIzNzE4NSwiZXhwIjoxNzU2ODQxOTg1LCJhcnRpY2xlSWQiOiJUMUVFT1ZHT1lNVEQwMCIsImJjb25uZWN0SWQiOiJCMUJDOTdEOTQ3MTg0OUExQkQ4MjIyN0MwMzJCRDQ4MiJ9.HLqQfvutk44IC3lA1IhaIxswFaW_hPb2bFX_nel9CVE&leadSource=uverify%20wall

The Errors Of The No Surprises Act

A great Health Affairs Forefront blog on the huge admin and steep payment costs in the No Surprises Act dispute resolution process. While Americans are being sheltered from surprise bills, the process is a mess and appears to be driving up overall costs in the healthcare system. Further, the process is being abused by a small sunset of greedy private equity-baced provider organizations.

A few findings from the blog:

• Providers have brought far more disputes than anticipated.
• They won 85% of the decisions in 2024.
• Providers receive fees that are three to four times the typical in-network rate.
• The high-volume of disputes is generating significant admin costs as well as higher payments. This will be recognized in overall healthcare costs and premiums.
• At least $5 billion in total costs have accrued through the end of 2024.
• In 2023 and 2024, 43% of resolved line-item claims were filed by two private equity-backed provider organizations: Radiology Partners and affiliates and Team Health. The top five provider organizations were responsible for 59% of line-item claims.

This is a tragedy and Congress needs to get a backbone and amend this provider-slanted law.

(Article may require a subscription.)

#nsa #nosurprisesact #transparency #providers #healthplans #surprisebilling

https://www.healthaffairs.org/content/forefront/substantial-costs-no-surprises-act-arbitration-process

EU-U.S. Tariff Accord Has Drug Tariffs

The EU-U.S. trade accord has established a 15% tariff rate for pharmaceuticals from the EU area. The vast majority of brand drugs consumed in the U.S. (60-75% based on value) are imported from the EU. Pharmaceuticals account for roughly a quarter of U.S. imports from the EU as measured by value. Generic drugs are exempt from the new agreement but remain subject to an earlier 2.5% tariff rate. The new tariff takes effect September 1.

President Trump has indicated that he plans on drug tariffs of as much as 250% over time to promote onshoring. He indicated tariffs would start slowly but eventually rise to that level. Drug costs in the U.S. will likely rise on the brand side due to the tariffs.

#drugpricing #tariffs #brands #generics

https://abcnews.go.com/Business/us-eu-release-details-tariffs-cars-pharmaceuticals/story?id=124843094

HHS Creates Federal Healthcare Advisory Committee

The Department of Health and Human Services (HHS) announced the creation of a Federal Healthcare Advisory Committee, which will drive reforms to restore patient-centered care in the healthcare system. The committee would be a group of experts charged with delivering strategic recommendations to improve how care is financed and delivered across Medicare, Medicaid and the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace. Further, the committee would find ways to cut waste, reduce paperwork, expand preventive care, and modernize CMS programs with real-time data and accountability. CMS is currently accepting nominations for committee members and is looking for experts in chronic disease management, financing in federal health programs, and delivery system reform. Individuals can either be nominated by an organization or submit a nomination for themselves.

The advisory committee will focus on developing:

• Actionable policy initiatives to promote chronic disease prevention and management;
• Opportunities for a regulatory framework of accountability for safety and outcomes that reduce unnecessary red tape and allow providers to focus on improving patient health;  
• Levers to advance a real-time data system, enabling a new standard of excellence in care, rapid claims processing, rapid quality measurement, and rewards;  
• Structural opportunities to improve quality for the most vulnerable in the Medicaid program; and
• Sustainability of the Medicare Advantage (MA) program, identifying opportunities to modernize risk adjustment and quality measures to assess and improve health outcomes. 

Additional article: https://www.cms.gov/newsroom/press-releases/hhs-drives-reform-restore-patient-centered-care-announces-request-nominations-members-serve-federal

#cms #hhs #medicare #medicaid #chip #healthcarereform #coverage #interoperability #fwa #exchanges #maha

https://www.fiercehealthcare.com/regulatory/hhs-form-committee-offers-guidance-medicare-medicaid

CVS Caremark Loses Whistleblower Suit

CVS Caremark, the pharmacy benefits manager (PBM) of CVS Health, has been ordered to pay more than $289 million in damages stemming from a 2014 false claims lawsuit.

The court originally set damages at $95 million after finding in favor of the whistleblower and finding CVS Caremark pushed insurers to overbill the Medicare Part D program. The judge has now tripled the settlement because the company’s actions were financially motivated and eroded public trust.

CVS Health said it would challenge the decision.

Additional articles: https://www.modernhealthcare.com/legal/mh-cvs-caremark-medicare-overbilling-lawsuit-2/ and https://www.beckershospitalreview.com/pharmacy/cvs-caremark-ordered-to-pay-290m-in-false-claims-suit/

(Some articles may require a subscription.)

#cvshealth #fwa #partd #aetna

https://www.fiercehealthcare.com/payers/pennsylvania-judge-hits-cvs-289m-fine-whistleblower-suit

Employer Healthcare Costs To Soar

After multiple years of high spending hikes for employer coverage, employers are facing perhaps a near-term record trend in 2026. The Business Group on Health released its annual survey and found that business firms are bracing for median cost increases of 9% in 2026. In the past two years, costs exceeded forecasts. And employers expect an 11% to 12% increase in pharmacy costs heading into 2026.

Ongoing demand for GLP-1s and other medications for weight loss is a significant cost driver. About 72% said that GLP-1s are impacting their 2025 healthcare costs to either a “great” or “very great” extent, up from 56% who said the same a year ago. The survey indicates that the number of employers covering these medications for weight loss may “stagnate” in an effort to control costs. Employers will also put on more guardrails like prior authorization. Some may end coverage.

Cancer is the leading driver of costs for the fourth year in a row. This trend is exacerbated by an increase in diagnoses and higher expenses for treatment. Mental health is also growing as a cost factor.

Employers are considering alternative pharmacy benefits managers (PBMs) and insurers as an option.

Finally, 66% are concerned the new tax law’s reductions to the Exchanges, Medicaid and Medicare will drive up hospital prices.

Additional articles: https://www.fiercehealthcare.com/payers/employers-brace-9-cost-increase-2026-business-group-health-survey and https://www.healthcaredive.com/news/employers-2026-healthcare-cost-trend-business-group-health/757907/

(Some articles may require a subscription.)

#employercoverage #commercial #healthcare

https://www.modernhealthcare.com/insurance/mh-employer-healthcare-costs-report-2026

Healthcare Lawsuits Galore

A good article from Modern Healthcare on various Medicare Advantage (MA) and Affordable Care Act (ACA) lawsuits.

Aetna, Elevance Health, and Humana are being sued by the federal government ove alleged kickback schemes to marketing organizations to steer beneficiaries to their plans.

Democratic-controlled states are suing the Trump administration over a new Exchange rule that tightens enrollment processes in the Exchanges.

There is an ongoing suit over the dispute resolution process under the No Surprises Act. The suit in part involves how the median in-network rate is calculated.

The Supreme Court largely sided with the government on the legality of free preventive services under the ACA but returned some issues to a lower court.

(Article may require a subscription.)

#aca #obamacare #medicareadvantage #exchanges #prevention #preventiveservices #nsa #nosurprisesact #marketing #fwa

https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-aca-lawsuits-regulation

Medicare Beneficiaries To See Part D Premium Hikes

Medicare enrollees in standalone Part D plans (PDPs) will see premium hikes in 2026. Premium hikes could be up to $50, although most will see something less. Increases might also hit those who enroll in a Medicare Advantage (MA) Part D.

The premium hikes occurred in 2025 and to a lesser degree in 2024. Spikes will be higher in 2026. The reason for the premium hikes include:

• Major drug price and utilization increases. One example is the uptake of GLP-1 weight-loss drugs used for those with chronic conditions like diabetes and cardiovascular disease.
• Changes in the Inflation Reduction Act (IRA) that limited cost-sharing in the program in a number of ways. A portion of the cost-sharing reductions were not funded and the costs and increased risk were put on plans. They had no choice but to pass on the costs in the form of higher premiums, pared back benefits, increased cost-sharing, and geographic contraction. The PDP program is becoming more and more precarious due to this short-sighted move by Democrats in 2022.
• To avoid negative election impacts, the Biden administration created a special premium stabilization program for 2025 that limited premium hikes by adding new government expenditures. This was a 3-year pilot. The Trump administration is seeking to reduce costs overall and has announced it will keep the program in 2026 but lower the dollars to plans. The stabilization effort next year will send $10 a month per enrollee to Part D insurers to help keep premiums in check, down from $15 this year. Insurers can raise premiums by as much as $50 a month, up from the $35 allowed this year.

The Trump administration was in a tough spot, inheriting a mess from the Biden CMS. The move to continue the stabilization program but at lower levels is not unreasonable despite the impact on enrollees.

#medicare #medicareadvantage #partd #pdp

https://kffhealthnews.org/news/article/medicare-part-d-premiums-rising-reasons/

Humana And DrFirst Team Up On Care Gaps

Humana and healthcare technology company DrFirst announced an expansion of their relationship aimed at closing care gaps. Humana suffered a huge loss of Star power in 2025. The focus initially will be boosting the use of statins among eligible members who are diabetics or have cardiovascular disease. DrFirst embeds in a physician’s electronic medical record system.

Additional article: https://www.fiercehealthcare.com/payers/humana-taps-drfirst-new-program-aimed-gaps-care-patients-chronic-needs

#medicareadvantage #quality #stars #humana

https://www.beckerspayer.com/payer/humana-drfirst-partner-on-program-targeting-chronic-conditions

Recap Of Q2 Health Plan Financials

A good recap in Modern Healthcare on Q2 financial results of big health plans and strategies they are employing to get back to margin. The secret in Medicare Advantage (MA) will be to prioritize margin over enrollment and growth. United and Aetna have already sent word they will pare back offerings. The secret in Medicaid will be strong lobbying efforts in each state for rates and to offset program reductions. Premium increases will dominate the Exchanges. I especially liked Elevance Health’s promise to continue legal challenges against providers on the No Surprises Act independent dispute resolution process. Bravo. It is abused by a small group of providers. In general, the provider-friendly process will drive up prices throughout the system.

(Article may require a subscription.)

#healthplans #margins #medicareadvantage #medicaid #exchanges

https://www.modernhealthcare.com/insurance/mh-aetna-cigna-unitedhealth-centene-q2-earnings