Health Care Dive

Denials ranged from 2% to 25% among insurers last year, according to a KFF analysis of new prior authorization data that the CMS forced insurers to release.

CHAI plans to create playbooks to help organizations defend against — and leverage — these powerful systems.

The court ruled Tuesday that insurers can’t include ghost rates or exclude bonus payments in calculating a metric used to determine reimbursement for out-of-network bills. That’s set to further inflate payouts to providers.

Respondents were split on who should solve the issues, with Democrats more likely to say the federal government and Republicans more likely to name insurers, according to a survey from the Commonwealth Fund.

PatientRightsAdvocate.org is challenging the doctor’s association’s copyright of the current procedural terminology, or CPT, system. Use of the codes is required by law, and that means they should be freely available, per the suit.

With the U.S. already facing a deficit of 86,000 physicians by 2036, healthcare cuts could push more rural hospitals to the brink of closure, according to a new study from staffing firm AMN healthcare.

The sector’s overall operating margin improved in 2025, but some providers lost ground as major federal funding cuts loom.

The findings could reflect a “mismatch” between expanding expectations for CFOs and the support systems available to finance teams, Deloitte said.

The rule made it harder for sick Medicaid enrollees to prove they’re exempt from work requirements than many expected. The CMS got sued. And now, the agency is being accused of fudging the data at the center of the rule.

CMS Administrator Dr. Mehmet Oz argues the rule will protect children from “irreversible harm.” LGBTQ+ advocates say the rule is an attack on transgender youth.

The libertarian think tank analyzed almost 130 studies digging into the controversial laws, which require providers to get state approval before building facilities or adding new services. What it found wasn’t good.

James “J.P.” Holland is taking the reins of Humana’s Medicaid business, a key growth area for the company, starting this coming Monday. It’s part of a broader leadership transition announced late last year.

The company says its patient portal should help translate medical jargon into plain language. It’s Oracle’s latest move to stand out in the competitive EHR market.

The executive order — which wasn’t accompanied by any new scientific evidence — aims to split the MMR vaccine into three separate shots and revives the administration’s attempt to slim down the immunization schedule.

In the aftermath of the breach, the dental and vision benefits administrator said it notified affected individuals in July and bolstered its security controls.

The Senate referred the former Ralph de la Torre, Steward Health Care’s former CEO, for possible prosecution nearly two years ago after he defied a congressional subpoena. Now, two Senators are asking for an update.

As lawmakers consider whether to enact site-neutral payments into law, one physician argues that reforming the Medicare payments would lower healthcare spending without hurting patient care.

Regulatory failures, funding constraints and industry consolidation have created serious hacking risks.

Unionized CVS pharmacists in three states greenlit a strike sanction last week as they seek better staffing levels and a seat at the table on CVS’ pharmacy decisions.

The sector added 22,000 jobs in July, well below the monthly average of 36,000 new jobs added in the past year. Still, healthcare buoyed what was otherwise a weaker-than-expected report for the economy overall.

The decertification of Network for Hope could disrupt organ donation in Kentucky, Indiana, Ohio and West Virginia.

It’s becoming harder for small employers to offer insurance coverage, and another year of double-digit premium increases won’t help. Insurers say their hands are tied.

NYU Langone Health and Dana-Farber Cancer Institute built an oncology decision support tool to guide clinicians through treatment. Now, the institutions are commercializing the product so other health systems can use it too.

Chief Executive Mike Dandorph will remain in the position through the end of September, after which he will be replaced by COO Phil Okala. Tufts is also swapping out its chief financial officer.

DeepHealth’s tool automates lesion detection, characterization and reporting from breast ultrasound scans.

“There’s not much more to say for CVS’ 2Q other than… wow,” one analyst commented. CVS also announced a new GLP-1 deal with Eli Lilly.

Facilities at the health system AnMed are still operating in a limited capacity as the nonprofit recovers from a cyberattack. Prolonged recovery times have become a problem in the industry, one expert said.

The value-based primary care provider submitted false diagnosis codes to the CMS for three years, inflating its reimbursement by millions of dollars, according to the DOJ.

The hospital juggernaut is adding Texas MedClinic’s locations to its nationwide portfolio of urgent care clinics amid rising consumer demand for fast and convenient medical attention.

Private consortiums have been attempting to put guardrails around the use of AI as federal regulations lag. HMH has been refining its AI governance structure for years, its medical informatics chief said.

Private consortiums have been attempting to put guardrails around the use of AI as federal regulations lag. HMH has been refining its AI governance structure for years, its medical informatics chief said.

Regulators also finalized the first nationwide, mandatory payment model to reduce the cost of joint replacements starting in 2028. Hospitals said the pay raise was inadequate, and chafed at the mandatory nature of the new model.

Half a year after major cuts to the Affordable Care Act exchanges went into effect, hospitals say more patients are going uninsured. That’s starting to drag their finances, for-profit hospitals say.

Regulators say the telehealth company illegally shared patients’ health data with advertisers and misled its customers. Hims & Hers hit back, calling the claims “baseless.”

The COVID-19 pandemic heightened vaccine skepticism. Six years later, CVS’ chief medical officer talks about building trust with patients — and the surprising benefits of many vaccines.

The Health Resources and Services Administration is again pushing to include rebates in the drug discount program after a failed attempt earlier this year. Hospitals railed against the announcement, saying it would burden already strapped providers.

A federal judge this week said he wasn’t convinced that regulation detailing work requirements would cause irreparable harm to states. Still, the court will continue to hear the case.

The deal to provide a range of imaging and therapeutic technologies to Cleveland Clinic extends the partners’ longtime relationship and follows a recent 10-year pact between Siemens Healthineers and Mayo Clinic.

Cigna increased its 2026 earnings outlook following the second quarter, unbothered by inflated costs for surprise billing dispute resolutions reported by its peer UnitedHealth.

Dr. Jaewon Ryu said he was stepping down to spend more time with his family. Risant is bringing out Dale Maxwell, a retired hospital executive, to serve as interim leader while it searches for a replacement.

The insurer is laser-focused on reaching margin targets, and will sacrifice some plans with lower returns next year to do so, CFO Celeste Mellet said.

The CMS said the program, which went into effect last year to stabilize Part D premiums and enrollment, isn’t needed anymore. One researcher said some enrollees could see higher premium increases in 2027 as a result.

Included is hoping that Firefly’s offerings will help set it apart in a crowded employee benefits space, especially as employers become increasingly open to alternative health plan arrangements.

Many employers are considering the coverage arrangements, but confidence in the ACA marketplaces — including potentially high costs for workers — are making them hesitant to move forward, according to a survey.

The managed care giant raised its 2026 earnings outlook for the second time this year following the results, which its CFO called “fantastic.”

The update is the latest in a COVID-19 vaccine mandate case brought by a former consultant against the Permanente Medical Group.

The regional nonprofit and surgical facility operator have co-owned the facilities since 2023. But Surgery Partners, which expects to net almost $800 million from the deal, is looking to reorient its portfolio to a more outpatient-heavy model.

The hospital operator recorded a $65 million hit from turbulence on the Affordable Care Act exchanges in the second quarter, but avoided the worse repercussions slamming some of its peers.

Selected devices will be exempt from certain premarket requirements while manufacturers collect real-world data through Medicare.

People formerly covered by the ACA exchanges are remaining uninsured almost on a one for one basis. “For us, obviously, it’s not a good thing,” CEO Sam Hazen said.

The Trump administration is fighting to restore controversial provisions that a judge threw out last month, including shorter sign-up windows and heightened eligibility verification.

Tuesday’s appeal is the latest development in Clover’s legal saga to get the CMS to recalculate its Medicare Advantage star ratings.

Providers and payers initiated 16% more disputes in the second half of 2025 compared with the first half, according to new federal data. But arbiters are closing challenges more quickly and tackling a backlog of disputes.

Molina’s second quarter was complicated, with stability in Medicaid and outperformance in Medicare Advantage overshadowed by problems in the ACA exchanges. The trend was “unfortunate,” according to the insurer’s CEO.

Brian Manning, who previously worked at health tech companies like Bamboo Health and Zocdoc, replaces the AI company’s co-founder and former CEO Alex LeBrun.

The rule pitched Wednesday would make it easier for group health plans regulated by ERISA to share mandatory notices with their members. A DOL official called the proposal a “big step forward.”

The new proposed rule is meant to prevent states from guaranteeing providers will be refunded for their taxes, and should save Washington $246 billion over the next decade, regulators said.

More Americans are keeping jobs they would otherwise leave for fear of losing their insurance, as healthcare costs rise and non-employer coverage seems less affordable, according to a new poll.

The deal is the latest in a series of pacts that GE HealthCare has made with health systems, including with Sutter Health and UC San Diego.

The HHS has halted more Medicaid funding to the states, citing concerns about fraud. Critics have slammed the “attack first, ask questions later” strategy of the deferrals, which have only impacted Democrat-led states to date.

The lawsuit follows a cease-and-desist request and argues Lilly is using “deceptive” ads to claim its GLP-1 products are broadly superior to Novo’s medicines. Lilly countered that its campaign is “truthful.”

The company agreed to buy a diabetes health business and medical supplier Strive Medical to boost its growing in-home solutions unit.

The cyberattack follows Abbott’s recent $21 billion purchase of Exact Sciences. Abbott did not disclose what kind of information was accessed.

Looming financial pressures in the healthcare sector, including cuts to Medicaid, are contributing to the rising rate of bankruptcies, according to the report by Gibbins Advisors.

Cost remains a major factor for employers as the popular drug for weight loss represented 11.4% of annual claims for corporations in 2025.

The insurer, which disclosed the breach in a securities filing late last week, doesn’t yet know how many people may have had their data accessed or what type of data was exposed.

It’s the latest evidence of rising spending in the drug discount program as regulators attempt to tamp down on growth in 340B.

On Thursday, a federal judge pressed pause on the CMS’ expansion of bare-bones catastrophic plans and other changes finalized in a rule this spring, saying they were likely to raise costs and hurt access.

Lawmakers introduced or advanced a raft of health legislation this week in advance of the midterm elections.

UnitedHealth’s profit spiked to $5.5 billion in the second quarter thanks to notable earnings recovery in its insurance and value-based care delivery businesses. The healthcare juggernaut delivered for investors, analysts said.

The Senate voted along party lines Thursday to defeat Democrats’ attempt to end WISeR, which they argue is delaying care for seniors.

A new report says doctors and nurses should train for cyberattacks the way firefighters train for major blazes — even if they expect them to be rare.

Venture capital funding deals worth $100 million or more made up nearly half of all money invested so far this year, according to Rock Health.

The program, a partnership with Kinomatic, will use biometric data and care coordination between visits to support recovery after surgery.

Terms of the deal announced Tuesday are very similar to those the FTC reached with Express Scripts earlier this year, including requiring the PBM to stop preferring higher cost versions of drugs on standard formularies.

Elevance will leave D.C. this summer and is considering other markets to depart, executives said. The company outperformed Wall Street expectations in the second quarter — but not by much, and its stock fell accordingly.

Physician groups said the sweeping rule is a double-edged sword, given it includes an unwelcome fee cut but positive changes to Medicare’s value-based and quality payment programs.

A federal judge dismissed another lawsuit brought by an Elevance health plan alleging the billings intermediary was gaming the arbitration process set up by the No Surprises Act.

SCAN Health Plan and Alignment Healthcare both filed lawsuits against the CMS last week after regulators refused to recalculate industry-wide MA scores using the same methodology as for Clover Health.

Hospitals and health systems recorded 18 transactions in the second quarter after a lull in dealmaking early last year as providers look to partner up to bolster their finances.

Payer mix changes, mostly from people dropping out of Affordable Care Act plans, caused HCA to lose $400 million in the second quarter — much more than the company (or its investors) had expected.

The HHS Office of Inspector General said it had kicked over 1,200 people and entities off federal programs between October and March as the Trump administration ratchets up oversight into what it says is rampant fraud in healthcare.

The model, which is set to sunset at the end of this year, generated $988 million in savings for Medicare in 2024, according to new CMS data. That’s up from almost $695 million in savings from the year prior.

The settlement could be the end of a long legal saga for Omnicare, which filed for bankruptcy last year after a judge ordered the company to pay nearly $950 million for fraudulently billing government health programs.

About 4,500 workers at Mass General Brigham are striking this week, while employees at Mount Nittany Medical Center in Pennsylvania said they would take to the picket line later this month.

Selling the unit, which provides an EHR for post-acute care, will allow the respiratory device maker to shift more resources to faster-growing parts of its portfolio.

A former executive is claiming that the MA insurer recorded millions of dollars as capital expenditures that should have been operating expenses, inflating its value. Alignment strongly denied the allegations.

ARHOME represents a small portion of Centene’s overall membership and premiums. But the exit represents how insurers are rejigging their businesses in advance of Medicaid work requirements, one analyst said.

“We have all this data that’s available, but it’s actually not actionable because we don’t have a way to get it into clinical workflow,” said American Medical Associaion CEO Dr. John Whyte.

Insurers are proposing a median premium increase of 14% for 2027, according to KFF, suggesting another year of double-digit premium hikes as policy upheaval and rising costs continue to roil the marketplaces.

HouseCalls has been accused of generating trumped up diagnoses to hike UnitedHealth’s Medicare reimbursement. But the review found almost 97% of diagnoses found in the home visits were backed up by patients’ medical records, UnitedHealth said.

The investment firms are leaning on joint ventures with nonprofits to expand in the healthcare sector, according to a new report from the Private Equity Stakeholder Project.

Ascension beat out other offers, including from HCA and Optum, to give Williamson a financial lifeline amid serious challenges facing regional hospital operators. The deal is expected to be final by 2028 at the latest.

The medical device supplier said that a threat actor accessed company systems through a social engineering attack.

Democrats are planning investigations into major healthcare topics if they win majorities in Congress this November. Healthcare firms should prepare for increased oversight now, experts say.

The medtech giant said it currently has no evidence that the accessed data has been posted to the internet.

Sumit Rana’s departure could be a significant leadership shakeup for Epic, as the president was viewed as a potential successor to the company’s 82 year-old CEO.

Medicare is spending more on quality bonuses despite fewer enrollees in eligible plans, the health policy research group said — a concerning trend putting more stress on Medicare’s coffers that could amplify calls for reform.

The rule, released Thursday, builds on Trump administration’s priorities, including cutting Medicare reimbursement for drugs in the controversial 340B program and equalizing payment between sites of care.

The deal brings Highmark Health-owned AHN’s hospital count to 16. The combined system will invest about $285 million over the next decade to bolster Heritage Valley’s facilities.

Regulators recalculated plans’ quality scores last month after losing a lawsuit to Clover Health. But they used a different methodology for Clover than its peers, causing Elevance to lose out on $115 million, the insurer told a court.

Express Scripts, Caremark and Optum Rx sued the FTC after the agency accused them of driving up the cost of insulin. But the countersuit is being put to bed now that the PBMs are settling with regulators.

Fewer companies may be impeding the flow of digital health information, but some could be doing so frequently, the ONC said. 

Millions could meet criteria to receive GLP-1s, which could cost Medicare billions of dollars, according to a report by KFF.

Steve Walsh, the CEO of a Massachusetts hospital group, will assume the top role in the early fall, after the AHA’s longtime leader retires.

Following Vijay Kumar’s exit, acting CBER Director Karim Mikhail will also oversee a review office that has become a battleground for debates on FDA flexibility.

Twenty-six states are seeking to overturn some of the regulation released by the CMS this month that outlined Medicaid work requirements — and asking the court to pause implementation for the time being.

The health IT regulator awarded a new contract to oversee the framework’s rules for data sharing as the number of health records exchanged through TEFCA balloons. 

Aidoc is working on an artificial intelligence feature that would analyze chest X-rays and generate preliminary reports for more than 100 findings.

ACA plan enrollment continues to shrink following the lapse of more generous subsidies last year, according to new federal data.

The Trump administration says its war on fraud applies to the entire country. But only blue states have had their Medicaid funding threatened or deferred, Democrats argued in a House subcommittee hearing Thursday.

Between 2020 and 2025, patient-written messages increased 153%, according to the study in JAMA. But office visits also rose, suggesting messaging doesn’t replace in-person care.

The healthcare sector wants the HHS to coordinate its AI strategy across agencies, provide implementation and governance support, and offer help in evaluating AI tools, leaders said Thursday.

Buyers are being more selective amid heightened policy and reimbursement pressure in healthcare, according to the analysis. Still, deal value is up compared to the first half of 2025.

The investigation by Florida’s attorney general comes as states look to check pharmacy benefit managers for allegedly driving up drug costs.

Utilization — not cost growth — continues to accelerate spending, government actuaries said. Spiking prescription drug spending, including on GLP-1s, is especially acute.

Incoming board member Lauren Tyler has more than 30 years of leadership experience in the finance world, which could help Centene navigate the challenging operating environment facing insurers.

The letter to the CMS from Democrats is the latest salvo from lawmakers concerned that WISeR is delaying care to Medicare beneficiaries.

No one’s going out of business without a merger, as both HMH and Hunterdon are on stable financial footing. But a combination will give the systems added heft to tussle with competitors, according to executives.

A series of newly planned reforms are designed to entice companies to start early trials in the U.S. rather than overseas.

To avoid losing funding, many states are pursuing proven cost-saving models, such as downsizing inpatient care, rather than novel, untested approaches, some experts say.

Dr. Michael Cuffe, who assumed the role in 2022, is leaving at the end of August.

Florence Chang, a long-time executive of the Washington-based nonprofit, will replace current CEO William Robertson on Jan. 1.

The drugmaker stopped paying 340B discounts to hospitals that didn’t comply with its new paperwork requirements late last week. Hospitals are urging HRSA to step in.

Regulators are locking in new 2026 stars for plans if they’re higher under the new methodology. But the recalculation basically results in no change to average star ratings unless you’re Clover, analysts say.

Employers are considering raising premiums and increasing other forms of cost sharing as they grapple with stubbornly rising health costs, according to a new survey from Mercer.

Joint Commission leaders break down the standards group’s new AI certification, explaining how it’s designed to work for everyone from major health systems to small rural clinics.

The drug middlemen lobby has had a busy week. It’s the second major lawsuit the PCMA has filed against a state law reforming the PBM industry since Monday.

Aaron Lewis, who has served as CFO since 2024, takes on the role as the health system looks to expand its footprint and add new services.

The No Surprises Act “might not have the effects that CBO anticipated,” the agency wrote in petitioning for more research into the 2020 law’s effect on healthcare prices and other trends. It’s a welcome development for payers.

The average number of issuers fell from a record high of 9.6 per state in 2025 to just nine this year, according to the health policy research group.

The proposed change adds Medicare coverage for beneficiaries with asymptomatic severe aortic valve stenosis who are enrolled in a CMS-approved study.

Express Scripts and the PBM lobby are following in CVS Caremark’s footsteps in filing complaints challenging the FAIR Rx Act, which was passed earlier this year despite vehement opposition from PBMs.

Most of Centene’s 61,000 employees will be eligible to apply for voluntary separation. But the program doesn’t amount to a complete overhaul of the company, a spokesperson said.

Most of Centene’s 61,000 employees will be eligible to apply for voluntary separation. But the program doesn’t amount to a complete overhaul of the company, a spokesperson said.

Friday’s decision is a victory for insurance advocates. But, given many of the rule’s provisions were codified in the GOP’s “Big Beautiful Bill,” it’s not a panacea for the ACA.

For 2029, a federal rule proposes closing a “loophole” that protects medicines transitioning from intravenous administration from price protection.

The tentative deal comes months after CVS Health reached a proposed settlement in the lawsuit alleging major pharmacy benefit managers are inflating insulin costs.

States will have to provide more rigorous financial analyses for their Medicaid demonstrations beginning in 2027, according to new federal guidance.

The company is working with Nvidia to build a foundation model for clinical conversations, and it scored a strategic investment from drugmaker Eli Lilly, Abridge announced during a sweeping keynote Thursday.

MA insurers commonly deny requests for post-acute care — but none more frequently than UnitedHealth, Humana and CVS, the HHS OIG said. Insurers were not happy about the findings.

The Office of Health Technology and Products is the latest technology development from the CMS as it doubles down on digital tools.

Nearly 70% of surveyed health plans said providers’ use of AI documentation and coding tools was a top three trend inflating commercial healthcare costs next year, according to a new report from PwC.

The insurer is offloading its interest in the massive end-of-life care provider to an undisclosed group of investors, amid widespread concern about private investors’ activity in healthcare.

Despite major financial struggles, some providers at a physician group in Washington, D.C. say their new — and much larger — parent is not offering the lifeline they want.

The trust fund underpinning Medicare’s hospital benefit is set to run out of money one quarter earlier than previously expected as tax cuts in the GOP’s reconciliation legislation shrink Medicare’s revenue.

A spokesperson said the layoffs were primarily in non-clinical or member facing roles.

Dr. Willie Underwood III said he would focus on uniting physicians across specialties and advancing equity in medicine as president.

It’s another sign of lawmakers’ concern about the pilot, which has been lambasted for delaying care to seniors.

AHIP argued the survey, which was commissioned by a pro-hospital advocacy group, is a blatant attempt by hospitals to deflect the blame for ever-higher spending.

Nearly 60 clinics have closed or consolidated with another site since last year, according to the report.

The rollout marks the second wave of deployments in 2026 after the VA largely paused the project for years to fix technical issues and errors.

The rollout marks the second wave of deployments in 2026 after the VA largely paused the project for years to fix technical issues and errors.

A federal judge ruled that the fee amounted to an unlawful tax on the visa program for highly skilled workers. Medical groups cheered the decision.

The state said it intends to divvy out new contracts, which represent tens of billions of dollars in revenue for each awardee, to six insurers. Winners are mostly incumbents, except for Humana.

City leaders said the regulation risks undermining the Affordable Care Act exchanges and adding new costs for local governments. Now, they’re suing to overturn the rule.

Many enrollees don’t know they’ll need to report work, education or volunteer hours starting in less than six months in order to stay covered, according to a recent survey from the Health Management Academy.

Americans are increasingly frustrated about being blocked off from care, which results in worse health outcomes and financial stress, per the new study. Still, insurers generally defend their claims review processes and argue improper denials aren’t their fault.