No Surprises Act dispute resolutions have driven $5B in costs, study finds

By Paige Minemyer – While the arbitration process established under the No Surprises Act is designed to protect patients from unexpected, out-of-network charges, a new analysis finds that managing these disputes is proving costly, too. The independent dispute resolution process, or IDR, is built on baseball-style arbitration to determine how much a provider will be paid for out-of-network claims and had been embraced in some states before the legislation established it as a federal process. Read Full Article...

HVBA Article Summary

1. IDR System Costs and Volume Far Exceed Expectations: From 2022 to 2024, the Independent Dispute Resolution (IDR) system incurred approximately $5 billion in total costs. This included $2.24 billion in additional payments from insurance plans to healthcare providers, $1.9 billion in internal administrative costs for payers and providers, and $656 million in fees paid to independent IDR entities. These figures far exceed initial expectations, as federal agencies had projected only about 22,000 disputes per year—yet over 3.3 million disputes were filed between mid-2022 and May 2025, indicating a massive underestimation of system usage.

2. Delays and Backlogs Due to High Dispute Volume: The overwhelming number of IDR filings has created significant backlogs and delays, making it extremely difficult for arbitration entities to meet the federally mandated 30-day deadline for decisions. By the end of 2024, the median time to resolve a line-item claim was 81 days, peaking at 96 days during some periods. Although the volume of disputes is the primary cause, procedural pauses resulting from court rulings have also contributed to the growing delays and system strain.

3. A Few Providers Drive Most Disputes and Payouts Are High: A small group of healthcare providers is responsible for a disproportionate share of IDR disputes, with Radiology Partners and TeamHealth alone accounting for 43% of cases in 2023 and 2024. The top five providers collectively made up 59% of all line-item claims. Furthermore, the payouts through IDR have increased substantially, with the median payment in late 2024 reaching 459% above the qualifying payment amount. These trends raise concerns about potential abuse of the system and have prompted discussions about whether policy changes are needed to curb usage and reduce inflated arbitration awards.

Is Life Insurance the Answer to the Growing Long-Term Care Need in the U.S?

By LIMRA – Each day, more than 11,000 Americans turn 65, and a majority (56%) of them will need some level of long-term care (LTC) services within their lifetime, according to the Department of Health and Human Services (HHS). Yet, LIMRA estimates just 3% of Americans over age 50 have any LTC insurance protection, leaving many people on the financial hook to cover these expenses on their own. Read Full Article...

HVBA Article Summary

1. Long-Term Care (LTC) Needs and Costs Are Rising: A growing number of Americans aged 65 and over will face significant long-term care needs. Statistics show that 56% will require LTC services, 45% will need paid care, and 14% may face out-of-pocket expenses exceeding $100,000. The financial burden is considerable, with the median annual cost of a home health aide now exceeding $77,000 and nursing home stays ranging between $111,000 and $127,000. These figures highlight the urgent need for financial planning around LTC as the population continues to age.

2. The LTC Insurance (LTCI) Market Is Adapting Through Innovation: The stand-alone LTCI market has contracted significantly due to premium hikes and underestimated costs, causing most carriers to exit by 2012. However, the persistent need for coverage has led to the rise of combination life/LTCI products, which blend life insurance with long-term care benefits. Insurers are now focusing on innovation, offering a wider range of flexible and affordable options tailored to middle-income and mass affluent consumers. This shift aims to increase accessibility while addressing past pricing and sustainability challenges.

3. Younger Generations and Caregivers Are Driving New Demand: A surprising new audience for LTCI is emerging: younger adults, especially Millennials in the “sandwich generation,” who often juggle caregiving responsibilities for both children and elderly parents. These experiences have increased awareness of their own potential care needs. Over 70% of caregivers say these responsibilities have influenced their views on planning for the future. As a result, there is growing interest in combination LTCI products that offer flexibility, peace of mind, and the ability to proactively manage future risks without burdening loved ones.

Cigna Intends to Unilaterally Downcode E/M Claims

By Luke Gale - Cigna has announced a new reimbursement policy that will automatically reduce payments for certain high-level evaluation and management (E/M) claims, drawing sharp criticism from physician advocacy groups who claim the move is illegal and burdensome to providers. Beginning October 1, the Evaluation and Management (E/M) Coding Accuracy Policy (R49) will apply to professional claims for level 4 and 5 E/M services. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Policy Change and Operational Burden: Cigna’s newly introduced policy allows the insurer to automatically downcode evaluation and management (E/M) claims by one level if it deems the submitted diagnosis insufficient to justify the reported complexity of the visit. To obtain the originally billed payment, providers must initiate a post-payment appeal and submit full medical records. This shift adds a new layer of administrative work and creates cash flow disruptions for healthcare providers, who must now spend additional time and resources navigating the appeals process.

2. Criticism from Medical Associations: Major physician advocacy groups, including the California Medical Association (CMA) and Texas Medical Association (TMA), have voiced strong objections to the policy. They argue it undermines clinical judgment by failing to account for the cognitive work involved in diagnosing complex cases—even when the final diagnosis appears straightforward. Furthermore, CMA suggests that the policy may be non-compliant with California law requiring payers to disclose detailed payment and coding rules used in claim adjudication.

3. Revenue Cycle and Administrative Impact: Healthcare revenue cycle leaders warn that the policy introduces new challenges by delaying reimbursement and increasing workload. The absence of a modern electronic submission system for appeals—potentially forcing providers to rely on fax—exacerbates inefficiencies and costs. Critics argue that the administrative burden may discourage busy practices from appealing every downgraded claim, effectively leading to systematic underpayment and increased financial strain on provider organizations.

GLP-1 coverage: A roadmap for balancing cost and care

By Katy Wong and Joy Sylvester – GLP-1 medications like Ozempic, Wegovy and Mounjaro have earned a reputation as “miracle drugs” due to their effectiveness in managing type 2 diabetes and weight loss, the latter fueling much of the public’s fascination. As their use expands, researchers are also exploring their potential for treating conditions ranging from Alzheimer’s and substance abuse to cardiovascular disease and more. However, as providers have widened the prescribed uses of GLP-1s, employers and benefits advisors are facing a growing challenge: How to offer access to these high-demand, life-changing therapies without undermining the financial sustainability of their health plans. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Clinical promise and growing demand: GLP-1 medications such as Ozempic, Wegovy and Mounjaro are effective for type 2 diabetes and weight loss and are being studied for other conditions, which has driven rapid increases in interest and utilization. That expanding use creates tension for employers and benefits advisors who want to provide access without undermining plan financial sustainability. The article emphasizes that addressing this requires data-driven strategies, thoughtful benefit design and proactive employee engagement rather than reactive cost-cutting.

2. Employer strategies and a case study from Memorial Hermann Health System: Memorial Hermann implemented prior authorization, strict eligibility criteria, integration with behavioral and wellness programs, reauthorization protocols and a $150 monthly copay to manage GLP-1 use. Those measures followed a 4x increase in utilization and net cost from 2023 to 2024 and reportedly reduced MHHS’s per-member, per-month GLP-1 spend by $15 while peer organizations experienced an average increase of $4 PMPM. The system also tied coverage to engagement metrics and reports stabilized utilizers and improved outcomes for employees who comply with the wellness requirements.

3. A roadmap and need for outcome data: The article outlines practical steps employers can take, including utilization management, aligning access with evidence-based weight-loss programs, cost-sharing to promote accountability, and careful monitoring with willingness to adjust criteria. It notes that 85% of employers that offer GLP-1s are considering additional restrictions for 2026, signaling continued scrutiny of coverage. Cohort studies and data-warehouse analyses are being constructed to compare long-term clinical outcomes and costs for those who receive GLP-1s versus those who are denied them, to better inform future benefit decisions.

Employers are missing the mark on delivering benefits workers value, surveys find

By Laurel Kalser – While companies pull “every lever to compete for talent,” making benefit decisions based on an inaccurate view of what their workforce values has a negative impact on retention, productivity and culture, Linda Keller, HUB’s chief operations officer of employee benefits, cautioned in a press release. Healthcare benefits is one area that needs better alignment, the surveys indicated. Read Full Article...

HVBA Article Summary

1. Health Concerns Impact Young Workers More Than Employers Realize: A significant portion of the workforce—41%—reports that health-related worries affect their ability to be present and productive at work. However, only 20% of employers identify health concerns as a major factor influencing productivity. This disconnect is particularly notable among younger employees: 45% of those aged 24–35 and 42% of those aged 18–24 say their health impacts their work, highlighting a blind spot in many companies' understanding of younger workers' needs.

2. Financial Stress Remains High, but Benefit Utilization Is Low: Financial wellness continues to be a critical concern for employees, with 46% prioritizing retirement planning and 44% valuing personal wealth planning tools. Some employers are stepping up, offering options like converting unused paid time off into student loan payments or 401(k) contributions. However, these efforts often fall short due to lack of awareness or understanding—75% of HR benefits managers surveyed by The Hartford report that employees underutilize available financial benefits, suggesting a gap in communication and education.

3. Strong Alignment on Time-Off Benefits Between Employers and Employees: Paid vacation and sick leave represent an area where employer offerings align well with employee expectations. According to HUB's findings, 94% of employers provide these benefits, and 97% of employees actively use them. Additionally, 91% of employees who don’t currently have access say they would take advantage of such benefits if offered. This high level of usage and appreciation indicates that time-off policies remain a valuable and effective component of total rewards packages.

Why skyrocketing health premiums should cause more alarm than gas prices

By Elizabeth Rosenthal – Wary of inflation, Americans have been watching the prices of everyday items such as eggs and gasoline. A less-noticed expense should cause greater alarm: rising premiums for health insurance. They have been trending upward for years and are now rising faster than ever. Consider that, from 2000 to 2020, egg prices fluctuated between just under $1 and about $3 a dozen; they reached $6.23 in March but then fell to $3.78 in June. Average gas prices, after seesawing between $2 and $4 a gallon for more than a decade starting in 2005, peaked at $4.93 in 2022 and recently fell back to just over $3. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Health Insurance Premiums Are Rapidly Increasing: Employer-sponsored health insurance premiums have more than quadrupled since 1999. From 2023 to 2024 alone, premiums rose by over 6% for both individuals and families—surpassing both wage growth and the overall inflation rate for the same period. In the ACA (Affordable Care Act) marketplace, premium increases are even steeper: proposed 2026 rate hikes include 66.4% in New York (UnitedHealthcare), over 33% in Colorado (HMO Colorado), 21.2% in Washington, and 23.7% in Rhode Island. On average, ACA insurers are requesting premium hikes of approximately 20% for the upcoming year.

2. Rising Costs Could Shrink the Insurance Market and Raise Risk Pool Costs: According to the Business Group on Health, actual health care costs have risen by a cumulative 50% since 2017. Many companies—87% in a 2021 survey—believe the cost of providing health insurance will become unsustainable within 5 to 10 years. As federal subsidies from the Biden era expire and GOP-led budget reductions cut healthcare spending, up to 16 million Americans could lose coverage by 2034. Many of those likely to drop coverage are younger and healthier individuals, which could worsen the risk pool and drive up costs even further for those who remain insured.

3. Limited Regulatory Power and Profit Motives Constrain Cost Control: State insurance regulators have the authority to scrutinize and reduce proposed premium hikes—particularly when increases exceed 15%—but their enforcement varies. Some states actively intervene, while others are cautious, fearing that strict regulation could prompt insurers to exit the market. Complicating the situation is that most U.S. health insurers are public, for-profit companies whose primary responsibility is to shareholders, not policyholders. Large employers may negotiate better rates due to scale, but small businesses and individuals must often accept higher premiums and rising deductibles, which for ACA silver plans now average nearly $5,000—double what they were in 2014.

Weight-Loss Pill Matches Injections, but Experts Skeptical

By Nadine Eckert – GLP-1 receptor agonists are now well established as weight-loss treatments, but until recently, they have been available exclusively as injections. Lilly, headquartered in Indianapolis, announced that the oral GLP-1 receptor agonist orforglipron reduced the average body weight by 12.4% in a phase 3 trial. The effect was comparable to that seen with injectable semaglutide, and German experts remain cautious about the findings. Read Full Article...

HVBA Article Summary

1. Orforglipron Demonstrates Significant Weight Loss Comparable to Injectable Options: In the ATTAIN-1 phase 3 trial involving over 3,100 participants with obesity or overweight and at least one weight-related comorbidity, those receiving the highest dose (36 mg) of the oral GLP-1 receptor agonist orforglipron lost an average of 12.4% of their body weight over 72 weeks. This outcome is only slightly below the 15.1% reduction reported for oral semaglutide (50 mg) in the OASIS 1 trial. Additionally, orforglipron treatment resulted in meaningful improvements in cardiovascular risk markers, such as lower triglycerides, non-HDL cholesterol, systolic blood pressure, and inflammatory markers like C-reactive protein.

2. Side Effect Profile Aligns with Other GLP-1 Therapies, Though Discontinuation Rates Were High: The safety profile of orforglipron was consistent with that of other GLP-1 receptor agonists, with gastrointestinal symptoms—such as nausea, vomiting, diarrhea, and constipation—being the most common adverse events. However, dropout rates were relatively high and dose-dependent; 24.4% of participants in the 36 mg group discontinued treatment, compared to 29.9% in the placebo group. These figures suggest that while the drug is generally tolerable, maintaining long-term adherence may be a challenge for some patients.

3. Experts Highlight Convenience, Limitations, and Broader Implications of Oral Delivery: While experts acknowledged the convenience of oral administration over injections, they cautioned against overestimating the results due to the placebo-only comparison. Concerns were raised about long-term effectiveness, muscle loss, potential overuse by non-critical patients, and the possibility of undermining lifestyle interventions like diet and exercise. Pricing, access, and therapeutic positioning are expected to influence its future adoption.