Aetna, Cigna, Elevance and UnitedHealth back new prior authorization standards push

By Allison Bell – Big health insurers said [Friday] that they will standardize the process for submitting requests for prior authorizations for coverage for many common procedures by Jan. 1, 2027. Managers of the standards effort will start by applying it to "medical services that are commonly subject to prior authorization, such as orthopedic surgeries and imaging services, including CT scans and MRIs," according to America's Health Insurance Plans. The effort will include commercial health plans as well as Medicare Advantage plans and Medicaid managed care plans, AHIP said. "Additional services will be added over time," AHIP said. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Industry-Wide Standardization Effort: Major health insurers, including Aetna, Cigna, Elevance, and UnitedHealth, are collaborating to create a unified process for prior authorization requests. The initial focus will be on frequently reviewed medical services, with plans to expand to additional procedures over time. This move aims to reduce administrative complexity for providers and patients by replacing disparate systems with a more consistent approach.

2. Potential Impact on Patients and Providers: If the new standards successfully accelerate prior authorization reviews, patients and healthcare providers could benefit from faster access to necessary treatments. However, employers and benefits advisors may need to monitor how these changes influence claim costs and access to care. The effectiveness of the new standards will likely depend on how thoroughly and uniformly they are implemented across different insurers and plan types.

3. Ongoing Policy and Legislative Developments: The push for standardization comes amid broader debates about the role and efficiency of prior authorization in healthcare. Recent legislative proposals in Congress seek to further streamline the process, particularly for Medicare Advantage plans, by mandating faster response times and increased automation. Meanwhile, pilot programs like the WISeR model in Original Medicare are being closely watched, as early feedback from providers has highlighted concerns about increased delays and administrative burdens.

Flash Drives and Funny Numbers: What Elevance Health’s Earnings Really Reveal

By Wendell Potter – For a company that beat Wall Street’s earnings expectations, Elevance Health had a lot of explaining to do Wednesday morning. The Indianapolis-based insurer posted first-quarter adjusted earnings of $12.58 per share — above what analysts had expected — and raised its full-year guidance. CEO Gail Boudreaux called the results a sign of “underlying business strength and improving claims experience.” But buried inside the same earnings release was a $935 million charge — the company’s “best estimate” of what it may owe the federal government for years of improper Medicare Advantage billing. Read Full Article...

HVBA Article Summary

1. Improper Medicare Billing and Regulatory Noncompliance: Elevance Health faces a $935 million charge related to years of improper Medicare Advantage billing, stemming from its use of non-approved methods for submitting data corrections to the Centers for Medicare & Medicaid Services (CMS). Despite repeated directives from CMS to use the required electronic systems, Elevance continued to submit corrections via encrypted flash drives and communicated its refusal to comply through multiple letters. This prolonged noncompliance led to the company collecting government overpayments and certifying data accuracy while knowing corrections were not properly made.

2. Financial Performance and Strategic Shifts: While Elevance exceeded Wall Street’s earnings expectations and raised its full-year guidance, its reported medical loss ratio (MLR) was significantly higher than that of its competitor UnitedHealth. The company’s Medicare Advantage membership dropped by 15.8% and Medicaid membership by 4.6%, reflecting a deliberate strategy to exit markets or shed members where profitability is not assured. This approach aligns with similar moves by other major insurers and highlights a prioritization of shareholder interests over maintaining coverage for vulnerable populations.

3. Market Reaction and Broader Industry Implications: The financial markets responded with relative indifference to Elevance’s large Medicare liability, treating it as a one-time charge rather than a sign of deeper operational issues. UnitedHealth’s stock, in contrast, rose following Elevance’s earnings release, suggesting investor confidence in the sector’s ability to manage cost pressures. The article underscores that the current system incentivizes insurers to maximize risk scores and self-report errors, contributing to widespread overpayments and raising questions about the alignment of insurer practices with public interest.

CFOs feel healthcare pain rising as GLP-1s stretch budgets, Mercer finds

By Alexei Alexis – Nearly three-quarters of U.S. finance leaders rank healthcare among their companies’ five biggest operating expense concerns, consulting firm Mercer found in a recent survey. The research comes as the rapid rise of GLP-1 weight-loss medications — like Wegovy and Ozempic — is adding to volatility in employer health costs. “The survey results make clear the far-reaching impacts of rising health benefit costs for individual organizations,” Susan Potter, president of Mercer U.S. and Canada, said in an emailed statement. “Only about one in four CFOs said that their organization was able to absorb the cost increases over the past two years without any business impacts, such as slower wage growth, reduced hiring, or higher prices.” Read Full Article...

HVBA Article Summary

1. Significant Increase in Employer Healthcare Costs: U.S. employer-sponsored health insurance costs are projected to rise by 6.7% in 2026, marking the highest increase in 15 years. This surge is expected to push the average expense per employee above $18,500, even after employers implement cost-saving measures. The increase is notably higher than recent annual trends, which averaged around 3% growth per year over the past decade.

2. GLP-1 Medications Drive Volatility and Budget Pressure: The growing use of GLP-1 weight-loss drugs, such as Wegovy and Ozempic, is contributing to unpredictable and rising healthcare costs for employers. These medications can cost between $1,000 and $1,500 per month, with employers often covering a substantial portion of the expense. About half of large employers currently cover these drugs for weight management, but some may reconsider this coverage due to the financial strain.

3. CFOs Respond with Plan Design Changes Over Premium Increases: As healthcare costs rise, nearly half of surveyed CFOs favor adjusting plan designs—such as increasing deductibles or modifying cost-sharing—rather than raising employee premium contributions. The volatility in healthcare claims and the acceleration of healthcare inflation, even as other sectors see cooling prices, are making it harder for organizations to manage budgets. Employers are also exploring stricter eligibility controls and support programs to manage utilization of high-cost medications.

LTD claims: What advisors and clients must know

By Justin Frankel – Based on our experience handling long-term disability claims nationwide, we believe greater transparency and education about underwriting practices, claims evaluation and claimant credibility benefit all stakeholders — policyholders, agents and insurers alike. How insurers evaluate risk during underwriting and claims review. Disability insurers evaluate risk at two critical points: before issuing a policy and after a claim is filed. During underwriting, insurers assess medical history, occupational duties, income and disclosed health conditions to determine eligibility, pricing and exclusions. This process is designed to evaluate future risk and ensure coverage aligns with the applicant’s disclosed profile. Read Full Article...

HVBA Article Summary

1. Disability Claims Shift to Ongoing Eligibility Review: Once a disability claim is filed, the process centers on whether the claimant meets the policy’s definition of disability and continues to qualify for benefits over time. Insurers review medical records, functional capacity, vocational factors, and treatment compliance as part of this evaluation. These assessments are continuous and may become more rigorous as the claim progresses.

2. Credibility Assessment Relies on Consistency and Context: Credibility is a key factor in claim decisions and is evaluated based on consistency across the full record rather than any single piece of evidence. Insurers may question discrepancies between statements and medical records, gaps in treatment, or limited functional documentation, and may also reference surveillance or social media activity. Many disputes arise from misinterpretation or lack of context rather than deliberate misrepresentation.

   Agents Play a Key Role in Guiding Claimants: Insurance agents can support clients by setting realistic expectations about the evidence-driven and potentially adversarial nature of the claims process. Emphasizing consistent medical documentation and focusing on functional limitations helps strengthen claims. Agents can also assist by identifying complex cases early and recommending experienced legal support when needed.

They’re in Remission, but Their Medical Bills Aren’t: Cancer Survivors Navigate Soaring Costs

By Renuka Rayasam – Nearly four years after doctors declared Marielle Santos McLeod free of colon cancer, she has yet to feel liberated from the burden of medical expenses. McLeod, who lives near Charleston, South Carolina, is still paying off chemotherapy bills that followed her 2017 diagnosis. She also now faces an onslaught of out-of-pocket costs for follow-up monitoring and care, including regular visits to a pulmonologist and allergist. McLeod, 45, said she had already spent $2,500 in the first two months of the year and owes an additional $1,300 from a January colonoscopy. That’s on top of the $895 monthly premium for a health insurance plan that covers her family of six. Read Full Article...

HVBA Article Summary

1. Ongoing Financial Burden for Cancer Survivors: Many cancer survivors continue to face substantial medical expenses long after their initial treatment ends. These costs include not only lingering bills from chemotherapy and procedures but also ongoing out-of-pocket expenses for monitoring and managing side effects. The financial strain can force survivors to make difficult choices about which care to prioritize or delay, potentially impacting their long-term health.

2. Policy Proposals and Insurance Gaps: Recent policy proposals aimed at lowering health insurance premiums, such as expanding high-deductible plans or allowing non-ACA-compliant coverage, may not address the needs of those with chronic or recurring medical costs. Experts and advocates warn that such plans could leave cancer survivors with inadequate coverage, especially if they have preexisting conditions. The risk of being denied coverage or facing exclusions for essential benefits remains a significant concern for this population.

3. Rising Costs and Limited Safety Nets: The overall cost of post-cancer care is projected to increase significantly in the coming years, with financial assistance programs already experiencing higher demand. Even with advancements in cancer detection and treatment leading to more survivors, the rising expenses can overshadow these medical successes. Many survivors report that worries about insurance and affordability influence major life decisions, such as career moves or further education.

Top 15 specialty pharmacies of 2025: Report

By Ella Jeffries – Pharmacy benefit manager-affiliated specialty pharmacies continue to dominate the market, with the top three companies accounting for two-thirds of prescription revenues in 2025, according to an April 21 Drug Channels report. Read Full Article...

HVBA Article Summary

1. Market Concentration Remains Strong: Despite an increase in the number of accredited specialty pharmacy locations, the market continues to be dominated by a small number of large players. The top three companies are responsible for a significant majority of prescription revenues, indicating limited competition at the highest revenue levels. This ongoing concentration may impact pricing, access, and innovation within the specialty pharmacy sector.

2. Growth in Hospital and Health System Pharmacies: Hospitals and health systems have significantly expanded their presence in the specialty pharmacy market, increasing their number of accredited locations from 106 in 2017 to 553 in 2025. These entities now represent over a quarter of all specialty pharmacy sites, reflecting a strategic move by health systems to capture more of the specialty drug dispensing market. This trend could influence patient care models and integration of specialty pharmacy services within broader healthcare delivery.

3. Independent Pharmacies Face Competitive Pressures: While independent specialty pharmacies make up the largest category by number of locations, they account for a smaller portion of overall revenue. The dominance of vertically integrated entities, such as those owned by PBMs and insurers, poses challenges for independents in terms of scale and negotiating power. As consolidation continues, independents may need to adapt their business models or seek partnerships to remain competitive.

GLP-1s May Reduce Asthma Exacerbations in Adults With Overweight and Obesity

By Heidi Splete – GLP-1 receptor agonists reduced asthma exacerbations among adults with asthma and excess weight but without diabetes in real-world study of more than 3000 individuals, presented at the American Academy of Allergy, Asthma & Immunology (AAAAI) 2026 Annual Meeting. “Asthma exacerbations can be disruptive for patients, especially those living with obesity, who often have fewer effective treatment options,” senior author Ruchi Patel, MD, internal medicine resident at Rutgers New Jersey Medical School, Newark, New Jersey, told Medscape Medical News. Read Full Article...

HVBA Article Summary

1. GLP-1 Receptor Agonists and Asthma Exacerbations: The study found that GLP-1 receptor agonists were associated with a significant reduction in asthma exacerbations among adults with overweight and obesity who did not have diabetes. This effect was observed consistently across different BMI categories, including overweight, obese, and morbidly obese individuals. The findings suggest that GLP-1 therapies may offer respiratory benefits beyond their established roles in diabetes and weight management.

2. Potential Mechanisms Beyond Weight Loss: While weight loss is known to improve asthma outcomes, the similar magnitude of risk reduction across all BMI groups indicates that GLP-1 receptor agonists may have additional mechanisms of action. These could include anti-inflammatory effects or other metabolic pathways that influence airway inflammation. The study authors highlight the need for further research to clarify these mechanisms and to determine whether the benefits are independent of weight loss.

3. Limitations and Future Research Needs: The study was observational in nature, which limits the ability to establish causality between GLP-1 use and reduced asthma exacerbations. There was also a lack of data on the duration of GLP-1 therapy and potential confounding factors related to weight loss. Experts recommend conducting prospective randomized trials to better understand the direct effects of GLP-1 therapies on asthma outcomes, especially in nondiabetic populations.

Companies are subsidizing health care for low-wage workers

By Alan Goforth – Employers across all industries, business sizes and geographies face the challenge of providing affordable health benefits as costs continue to rise. "Employers can offer markedly different health benefit experiences for workers, affecting access to care, the affordability of coverage and the scope of benefits provided," a new report from Peterson-KFF Health System Tracker said. "As the cost of health insurance increases, employers continue to grapple with what types of benefits their employees want, how much to spend and how to share costs with employees." Participation in employment-based coverage is tied to affordability. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Affordability Remains a Major Barrier: Many employees, especially those with lower wages, are opting out of employer-sponsored health coverage due to the high cost of premiums. Employers are aware that affordability is closely linked to participation rates in health plans. This challenge is prompting organizations to reconsider how much of the cost burden is placed on workers versus the company.

2. Employers Are Adopting Tiered Strategies: To address the needs of low-wage workers, companies are introducing lower-priced, less-generous health plan options and adjusting contribution amounts based on employee wage levels. While these strategies can help more workers enroll in coverage, they may also expose employees to higher out-of-pocket costs if significant medical care is needed. Some employers are also subsidizing contributions for lower-wage employees to make more comprehensive plans accessible.

3. Education and Plan Choice Are Key Considerations: Employers are not only offering a range of plan options but are also focusing on educating employees to select the most appropriate coverage for their needs. For example, some companies are introducing new "value plans" and providing resources like open enrollment guides and employee meetings to help workers make informed decisions. The goal is to balance affordability with adequate coverage while ensuring employees understand their options.