Payer

The Future Must Be Less Wasteful, More Collaborative Misaligned policies, medical necessity screening tools, and incomplete clinical data are chief contributors to rising claims denial rates. They’re a challenge that costs hospitals and health systems nearly $20 billion per year,…

Humana plans to open between 20 and 30 primary care clinics in 2025. 

Seventeen HCA hospitals in Florida are suing UnitedHealthcare for allegedly underpaying for emergency care provided to its ACA members. 

The president of an insurance brokerage firm and the CEO of a marketing company have been charged for their alleged roles in a scheme to submit fraudulent enrollments for fully subsidized ACA plans in order to obtain millions of dollars…

Blue Cross and Blue Shield of Alabama is criticizing a proposed health plan backed by the Alabama Farmers Federation (ALFA), which BCBS says would provide unregulated coverage, harm members, and discriminate based on pre-existing conditions. 

Centene and one of its subsidiaries will pay $11 million to settle allegations the company falsely certified its compliance with cybersecurity requirements. 

Blue Cross Blue Shield of Michigan will begin enforcing a long-standing policy that would charge hospitals that repeatedly appeal denied claims.  

Medicare Advantage insurers are navigating headwinds in 2025, and new data shows prior authorization requirements within the program continuing to grow. 

Humana's chief medical officer, Kate Goodrich, MD, says CMS' proposed Medicare Advantage rate increase for 2026 "does not fully account for" the rising medical costs experienced by the company over the last few years.

Major insurers are investing further in the stop-loss insurance business, while others are grappling with mounting cost pressures in the same business line.