April 28, 2025
Lauren Berryman
Elevance Health is facing a second lawsuit accusing it of maintaining inaccurate provider directories, also known as “ghost networks.”
The plaintiffs are three people covered under New York state employee health benefits who allege that Elevance Health division Carelon Behavioral Health misrepresented providers as in-network, causing them financial harm. The attorneys are seeking class-action status.
Legal experts expect “ghost network” lawsuits to spread. Health insurers have long faced criticism for faulty provider directories.
April 09, 2025
Nona Tepper
Health insurance investors cheered after the Centers for Medicare and Medicaid Services granted Medicare Advantage carriers their largest pay increase in a long while.
Wall Street reacted enthusiastically to the 5.1% payment hike for 2026 that CMS finalized Monday, which could signal a more favorable regulatory environment under Republican President Donald Trump than during the four years Democratic President Joe Biden occupied the White House. Health insurance stocks jumped 8.4% when the markets opened Tuesday.
April 02, 2025
Bridget Early
The Health and Human Services Department is restructuring agencies that enforce regulation, handle claims disputes, and investigate potential civil rights violations as part of a department-wide reorganization.
A new assistant secretary for enforcement will oversee three parts of HHS — the Departmental Appeals Board, the Office of Medicare Hearings and Appeals and the Office of Civil Rights — as part of a sweeping overhaul announced last week. The new role raises questions about how HHS plans to handle billions of dollars in claims disputes and appeals resolutions, as well as how the offices will operate within the new structure.
March 13, 2025
Alex Kacik
Hospitals could lose billions of dollars in revenue if states roll back Medicaid expansions due to potential Medicaid cuts.
House Republicans proposed hundreds of billions of dollars in Medicaid cuts, potentially including per capita caps, work requirements and eliminating enhanced federal payments for states that expanded Medicaid coverage. Hospitals may lose $32 billion in 2026 revenue if Medicaid expansion is curtailed, an analysis released Tuesday by the left-leaning think tank Urban Institute shows. Coverage losses could also increase providers’ uncompensated care costs.
March 03, 2025
Lauren Berryman
UnitedHealth Group is taking another step to refine its prior authorization requirements as it continues to face public frustration. The healthcare giant’s insurance business, UnitedHealthcare, plans to cut nearly 10% of prior authorizations this year, the company said in a notice Saturday.
As part of the initiative, the insurer said it will remove pre-approval requirements for home health services managed by its home and community division. The changes will apply to Medicare Advantage and dual special needs plans in 36 states and Washington, D.C., starting April 1.
February 19, 2025
Nona Tepper
Health insurance customers in more parts of the country have new advocates in their battles against claims denials: state governments.
States have long had regulatory authority over the individual and small-group health insurance markets, but a growing number of agencies is taking on a greater role assisting consumers as they transition out of a federal system and take matters into their own hands.
State officials see homegrown solutions as more effective at handling large numbers of complaints. Pennsylvania, for instance, established an independent external review board in 2024 while Arizona launched a program at the start of this year.
February 11, 2025
Michael McAuliff
Lawmakers say they are confident Congress will extend expanded telehealth authorities past a looming deadline next month — but they have no idea how and could not rule out a lapse.
In 2020, Congress and President Donald Trump temporarily expanded Medicare reimbursement for services clinicians provide remotely as part of the response to the COVID-19 pandemic. Lawmakers have hailed extended telehealth rules for providing lifelines to rural and underserved populations in particular, prompting some to propose bills last year to make the changes permanent.
January 29, 2025
Nona Tepper
Promising signs for “public option” health plans sold on state health insurance exchanges spell bad news for providers, who say they’re squeezed by low reimbursements.
Colorado and Washington are the only states that have government-sponsored — but privately administered — public options on their marketplaces. Nevada is set to join them soon and other states may follow. Public option enrollment climbed on Connect for Health Colorado and Washington Healthplanfinder during the open enrollment period that ended Jan. 15, the states reported.
January 22, 2025
Nona Tepper
Healthcare providers say insurance companies are innovating new ways to make it harder to get paid.
Physicians, hospitals and other providers have always complained of low rates, delayed payments and the usual red tape. But rules insurers such as Blue Cross Blue Shield of Michigan, UnitedHealthcare and Elevance Health have recently announced may be a new battleground in the age-old fight between the two camps.
Health insurance companies justify utilization management and claims review as crucial to constraining healthcare spending and ensuring that patients receive appropriate care.
January 15, 2025
Bridget Early
The Drug Enforcement Administration is proposing a rule in the Biden administration’s final days that would establish a special registration process for remote prescribing of certain drugs.
On Wednesday, the DEA released a proposed rule that would set up a special registration process for remote prescribing of Schedule II-V controlled substances such as Xanax, Vicodin and Adderall. It also released a final rule for its 2023 proposal that sets up a special registration process for remote prescribing of buprenorphine, a medication used to treat opioid use disorder.