CMS is launching its long-term enhanced accountable care organization design, or LEAD, model at the end of 2026, following the conclusion of the ACO realizing equity, access and community health model. Previously, CMS set a goal to have all traditional…
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Minnesota is rehabilitating UCare, according to a Dec. 17 court filing. The state will take over the insurer’s assets and finances. While providers cannot collect payment from UCare during this time, provider contracts could be modified under the state’s supervision.…
Payers have faced state penalties in 2025 for slow reimbursements, improper claims denials, and mental health parity violations. Fines in 2024 are here. Payers fined by states in 2025:
CMS will launch a voluntary pilot in 2026 to gather service-level data on prior authorization determinations and appeals in Medicare Advantage, according to a Dec. 16 memo. After the pilot, the agency expects to expand the data-collection efforts to all…
Humana’s Louisiana business received at least $10.5 million in Medicare Advantage overpayments in 2017 and 2018, according to an audit report from HHS’ Office of Inspector General. The audit, published in December, reviewed high-risk diagnosis codes including acute stroke, acute…
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Evry Health CEO and co-founder Chris Gay thinks the health insurance industry could eliminate prior authorizations entirely, but only if providers meet insurers halfway. On the Becker’s Payer Issues podcast, he spoke about the technology and business model problems fueling…
Health plans were early adopters of AI, using it to streamline claims processing, support call centers and manage utilization. Now, they’re ramping up AI deployment to enhance member experience, improve care quality and reduce administrative costs, according to America’s Health…
Clever Care Health Plan is pairing its culturally competent care model with a new provider network partnership built around the lifestyle habits of the world’s longest-living populations. The partnership launches in 2026 and will connect Clever Care’s 40,000 Medicare Advantage…
Neither bill proposing solutions to the impending ACA enhanced subsidy expiration survived a Dec. 11 Senate vote. While Senate Democrats advocated for a three-year ACA tax credit extension, Republicans pitched an alternative focusing on health savings accounts. Both motions failed…
CMS’s proposed Medicare Advantage rule for 2027 includes more leeway for hemp coverage. Hemp has low concentrations of tetrahydrocannabinol, as defined by the Agriculture Improvement Act of 2018. Under the proposal, hulled hemp seed, hemp seed protein powder and hemp…