improperpayments

More Suits On No Surprises Act UnitedHealthcare joins the ranks of Elevance Health and Aetna in suing prominent provider entities over the No Surprises Act. United is suing Radiology Partners and its Arizona-based affiliate, Sonoran Radiology, alleging the companies have been “abusing” the No Surprises Act’s independent dispute resolution process. They argue the radiology provider behemoth is “funneling millions into the pockets of its private-equity owners.” The lawsuit comes after a Health Affairs study that shows that providers overwhelmingly win disputes and are awarded extremely high payments. Another new study also shows that surprise bills have fallen under the act based on data from states that had some protections and those that did not before the national law took effect. The study also notes that the prediction that the process would lower prices and save has not materialized. The fact remains the law needs major reform, including requiring the qualifying

State Insurance Commissioners Between The Proverbial Rock And A Hard Place Modern Healthcare has a good article reviewing the plight this year of the insurance commissioner. Healthcare costs are spiraling, in part due to utilization and in part higher prices throughout the sector. As well, the One Big Beautiful Bill Act (OBBBA) is anything but cheerful for most consumers reliant on the Exchanges. The bill will contract enrollment dramatically. This is leading to greater risk in the program and plan and product exits. The combination of the two have insurers putting in for massive rate hikes in the Exchange program. Insurance regulators do have a hard task. They need to ensure that insurance rates are affordable and consumers have access to the market. They need to protect against excessive hikes. But they also need to ensure a stable and secure insurance marketplace and that means granting sufficient rate hikes to

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

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: 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 Humana In Enviable Position Compared With United Interesting article in Modern Healthcare comparing the relatively enviable position of Humana, with surging stock prices, right now vs. the current meltdown suffered by UnitedHealth Group. Of course, a great deal is attributable to the fact that Humana recognized

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 A Second Budget Reconciliation Bill With Healthcare Cuts Conservatives in and out of government are looking

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: 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

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 Health Plans Turn To Variable Copay Plans To Lower Costs More health plans are turning to variable copay plans to reduce costs and offer lower cost alternatives to employers and avoid passing on more premium and deductible costs on employees. MN-based HealthPartners said it will offer a

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

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 BCBSMA Reports Q2 Loss Blue Cross and Blue Shield of Massachusetts reported a net loss of $129.7 million on revenue

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: 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/ On Drug Tariffs And Onshoring Eli Lilly is speaking out against proposed tariffs on pharmaceuticals, saying they could increase drug costs and restrict patient access. I would agree this is the case on generic drugs for sure.