Who's Really Gaming the No Surprises Act?

By Wendell Potter – Health insurers have a new talking point – based on a new “ study” by the giant health insurance conglomerate Elevance Health – and it goes something like this: Doctors are exploiting the No Surprises Act’s (NSA) arbitration process to extract outrageous payments, and something must be done before the whole system collapses under the weight of runaway awards. Read Full Article...

HVBA Article Summary

1. Elevance Study Examines a Narrow Slice of Disputes: The insurer-funded analysis reviewed about 7,300 payment disputes involving scheduled procedures, representing less than 1% of all claims submitted through the arbitration system. According to the report, providers prevailed in nearly 90% of those cases, and some awards exceeded insurer benchmarks. The author argues that Elevance uses these findings to suggest the arbitration framework is broadly dysfunctional. He contends the limited sample size makes it inappropriate to generalize about the entire No Surprises Act process.

2. Low Initial Offers May Skew Arbitration Outcomes: The article asserts that large arbitration awards can reflect insurers’ initial payment offers being set unreasonably low. It cites examples such as emergency department billing codes allegedly assigned qualifying payment amounts of under $1 and a breast implant procedure where the insurer’s benchmark was six figures but the payment offer was zero. In these scenarios, arbitration outcomes may appear outsized only in comparison to the original offer. The author argues this dynamic challenges the narrative that physicians are systematically exploiting the system.

3. Legal Scrutiny of Insurer Payment Practices: The piece highlights ongoing legal actions, including a lawsuit by Arizona’s attorney general against MultiPlan and several major insurers, including Elevance. The complaint alleges the use of shared pricing algorithms and pooled data to suppress out-of-network payments across the industry. Additional federal antitrust litigation and class actions are also underway, with the Department of Justice reportedly supporting providers in one case. The author frames these allegations as central to evaluating who may be influencing or “gaming” payment outcomes under the law.

Rising health care costs are straining Texas businesses as the Legislature seeks solutions

By Paul Cobler – The expenses to operate three restaurants in Waco are rising across the board, but there's one growing cost in particular that feels nearly impossible to manage — providing employee health insurance, co-owner Kyle Citrano said. "Every year, it can change on you in a heartbeat," said Citrano, whose family runs George's, George's #2 and Jorge's Cantina. "You could have your rates jump because your participation is down, someone on your staff could get hurt. You never know." Read Full Article...

HVBA Article Summary

1. Rising Premiums Are Squeezing Employers and Workers: Health insurance costs for businesses are climbing faster than many other operating expenses, with national projections showing a 9% increase in 2026 and family coverage averaging nearly $27,000 per year. Employers report that these increases reduce funds available for wage growth and hiring. In some cases, companies are shifting more costs to employees through higher premiums and deductibles. This dynamic can lead lower-paid workers to forgo coverage altogether, affecting both health outcomes and workplace productivity.

2. Market Consolidation and Limited Transparency Drive Costs: Experts and employer advocates argue that consolidation among hospitals and pharmacy benefit managers has reduced competition and enabled higher prices. More than 1,300 hospital mergers have occurred nationwide since 2000, and four major PBMs now control about two-thirds of the market. Employers say they often struggle to obtain detailed pricing data for procedures and prescriptions, limiting their ability to negotiate better rates. Hospital representatives counter that consolidation can help keep financially vulnerable facilities, especially in rural areas, open.

3. Texas Lawmakers Signal Bipartisan Interest in Reform: Legislative leaders in both chambers have directed committees to explore solutions ahead of the next session, with a focus on transparency and competition. Proposals under discussion include requiring clearer upfront pricing for treatments and strengthening oversight of mergers and anticompetitive practices. Lawmakers also highlight the state’s ability to collect and publish ownership and pricing data to make the market function more effectively. The issue has broad public salience, with 89% of Texas voters expressing concern about health care costs in a recent poll.

ACA plans set for another year of premium spikes, preliminary filings show

By Paige Minemyer – Plans on the Affordable Care Act's exchanges are set for further premium increases next year, a new report shows. Analysts at KFF dug into preliminary rate filings from payers for the 2027 plan year and found a median proposed premium increase of 14%. The report is based on filings from 16 states and the District of Columbia, representing 77 insurers. Read Full Article...

HVBA Article Summary

1. Exchange Premium Increases Continue to Accelerate: Preliminary 2027 Affordable Care Act (ACA) marketplace filings indicate that most insurers are requesting premium increases between 10% and 20%, with 20 carriers seeking increases exceeding 20%. If approved, exchange premiums will have increased by more than one-third between 2025 and 2027. KFF's analysis also found that the largest group of insurers (35) is requesting increases in the 10% to 15% range.

2. Medical Cost Growth Remains the Primary Driver: Insurers consistently cited rising healthcare costs as the leading reason for higher premiums, with the median projected increase in medical and pharmaceutical costs reaching 10%, exceeding recent historical trends. Additional contributors include broader economic inflation, labor shortages, continued demand for GLP-1 medications, and higher supply chain and pharmacy costs. Several insurers also reported that providers are coding more services at higher acuity levels, increasing reimbursement rates without corresponding evidence of improved patient outcomes.

3. Utilization Trends and Policy Changes Are Adding Cost Pressure: Multiple insurers reported sustained increases in healthcare utilization, particularly for outpatient surgeries, behavioral health services, and medical pharmacy spending, which are contributing to higher claims costs. Payers also identified recent federal policy changes—including implementation of provisions under the One Big Beautiful Bill Act, evolving CMS regulations, and the expiration of enhanced premium tax credits—as factors influencing 2027 rate requests. In addition, some insurers, including UnitedHealthcare of New York, incorporated costs associated with the No Surprises Act's Independent Dispute Resolution process into their premium calculations, citing its impact on overall medical spending.

PBM compliance post in Alabama filled by criminal law specialist

By Allison Bell – The Alabama Department of Insurance has hired a lawyer who knows about criminal law and prisons to help it expand its pharmacy benefit manager law enforcement efforts. The department named Thomas McCarthy to serve as senior PBM regulatory counsel at the department's PBM compliance division. McCarthy previously was deputy general counsel at the Alabama Department of Corrections. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Criminal law background signals stricter enforcement: Thomas McCarthy’s experience as a former prosecutor and deputy general counsel for the Alabama Department of Corrections suggests the state may pursue aggressive enforcement of its pharmacy benefit manager laws. Officials highlighted his work on numerous criminal cases and jury trials, underscoring his courtroom experience. His appointment indicates that Alabama is preparing for potentially contentious regulatory disputes. The move may also serve as a warning to PBMs that compliance will be closely scrutinized.

2. Alabama building a formal PBM compliance infrastructure: The state’s enforcement push follows legislation signed by Gov. Kay Ivey in April 2025 aimed at strengthening PBM oversight. In response, the Department of Insurance established a dedicated PBM compliance division in September 2025. Leadership of the division was formalized with the appointment of Dr. Kelli Littlejohn as senior director in November 2025. Together, these steps show a structured and phased effort to institutionalize PBM regulation.

3. Part of a broader national trend and legal battle: Alabama joins several other states, including Arkansas, Tennessee and Texas, in adopting tougher PBM laws. These measures have frequently led to lawsuits from employer plan sponsors and PBMs, particularly over whether states can regulate plans governed by ERISA. The legal uncertainty has created ongoing conflicts between states and industry stakeholders. Alabama officials have stated they aim to build one of the nation’s most comprehensive PBM compliance programs amid this evolving landscape.

How brokers can become ‘AI whisperers’

By Susan Rupe – A benefits broker can become an “AI whisperer” by giving artificial intelligence tools assignments instead of asking them dumb questions. Reid Rasmussen, founder and CEO of freshbenies, described how brokers can improve their AI skills during the National Association of Benefits and Insurance Professionals annual convention. Read Full Article...

HVBA Article Summary

1. Prompt Quality Determines AI Output: Rasmussen emphasized that vague or simplistic prompts often lead to generic and unhelpful responses from AI tools. He demonstrated that adding context, audience details and constraints significantly improves the usefulness of the response. By treating AI as a drafting assistant rather than a finished-product generator, brokers can refine outputs into client-ready communications. The responsibility for quality, he argued, rests largely on how well the user frames the request.

2. Use the WHISPER Framework for Better Results: Rasmussen introduced the acronym WHISPER—what, how, intent, specificity, persona, examples and requirements—as a structured way to craft stronger AI prompts. Brokers are encouraged to clarify the task, define the format, explain their objective and outline constraints such as tone, compliance needs and length. Providing this level of detail helps AI generate responses aligned with business goals and audience expectations. The framework turns AI use from casual experimentation into a repeatable professional process.

3. Personalization and Strategic Judgment Still Matter: Rasmussen advised brokers to assign AI a persona, such as a communications strategist or skeptical CFO, to tailor responses more effectively. He also recommended feeding AI background information about one’s company, responsibilities and challenges to create more customized outputs. While AI can help automate preparation and improve communication, he stressed that clients ultimately value professional judgment over word generation. The goal is to enhance client value and strategic thinking, not to replace the broker’s expertise.

Beyond Weight Loss: The Expanding Role of GLP-1s in Oncology

By Coral Olazagasti, MD – This transcript has been edited for clarity. Coral Olazagasti, MD: Hi, everyone. Good afternoon. My name is Dr Coral Olazagasti, and I’m a medical oncologist from the University of Miami. I’m excited to be here with my colleague and my friend, Carolina. Dr Bernabe, Can you please introduce yourself? Read Full Article...

HVBA Article Summary

1. Retrospective Data Suggest Survival Benefits in Solid Tumors: A retrospective database analysis of roughly 1000 patients with a history of cancer who were taking GLP-1s found a 24-month overall survival benefit in breast and prostate cancers. Although retrospective, the study used statistical adjustments, including propensity score matching, to account for age and other factors. The survival signal remained after these adjustments, strengthening the association. The findings raise questions about whether similar benefits might be observed in other tumor types.

2. Potential Synergy With Immune Checkpoint Inhibitors: A separate retrospective cohort of approximately 3800 patients examined those receiving both GLP-1s and immune checkpoint inhibitors. Patients on the combination experienced improved survival outcomes compared with those not on GLP-1s. In addition, the analysis found lower rates of immune-related adverse events among GLP-1 users. These observations suggest GLP-1s may influence both efficacy and tolerability of immunotherapy.

3. Emerging Role in Inflammation and Supportive Care: The discussion highlighted the possibility that GLP-1s may reduce tumor-associated inflammation and modulate the tumor microenvironment. Clinicians also speculated about a future role as steroid-sparing agents, particularly for patients at risk of autoimmune complications during immunotherapy. Beyond survival, there is interest in whether GLP-1s could help manage treatment-related side effects such as edema or metabolic disturbances from targeted therapies. Prospective trials will be needed to confirm these hypotheses and define their place in routine oncology practice.

The hidden assumption in every benefits strategy

By Ben Conner – There is a quiet assumption embedded in almost every benefits strategy in America: We treat insurance companies as if they are healthcare companies. That assumption influences the way brokers advise clients, the way employers structure plans and the way employees think about the ID card in their wallet. It shapes conversations about networks, plan design and cost control. And yet, when you step back and examine the system honestly, the assumption doesn't really hold up. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Insurers function primarily as financial intermediaries: The author argues that insurance companies are structured more like banks than healthcare providers. Their core role is to collect premiums, pool financial risk and distribute payments across the system rather than deliver medical care. Viewing them as healthcare organizations can blur accountability and distort strategy. Reframing insurers as financial institutions changes how employers and brokers should define their responsibilities.

2. Network expansion has weakened price leverage: Large insurance networks were originally intended to use patient volume to negotiate discounted rates. However, in many markets nearly all providers are included, which reduces insurers’ bargaining power. According to RAND research cited in the article, commercial plans pay 254% of Medicare rates on average for the same services. This dynamic can embed higher prices into contracts and increase employer healthcare spending over time.

3. Employers can reshape the healthcare supply chain: Because employers ultimately fund health benefits, the author contends they should take a more active role in structuring how care is accessed and paid for. Treating insurers as one component of a broader ecosystem could allow companies to remove unnecessary intermediaries and introduce greater transparency. Increased visibility into pricing and quality may encourage genuine competition among providers. This shift could also expand the advisory role of brokers beyond plan design toward broader healthcare strategy.

AdaptHealth discloses patient data was stolen in cyberattack

By Ricky Zipp – AdaptHealth disclosed last week that a recent cyberattack resulted in patient data being stolen. A threat actor gained unauthorized access to company systems through a social engineering attack and exfiltrated data, including certain personally identifiable information, protected health information of patients and stored password files associated with insurance billing, according to a July 2 filing with the Securities and Exchange Commission. Read Full Article...

HVBA Article Summary

1. Social engineering attack led to unauthorized access: The company said a threat actor gained entry to its systems through a social engineering attack that compromised a user session tied to a third-party contractor. The attacker accessed certain cloud-based business applications, including internal patient management systems and document storage platforms. External electronic health record portals were also accessed. The breach involved data exfiltration, meaning information was taken from the systems rather than merely viewed.

2. Scope of stolen data still under investigation: AdaptHealth confirmed that personally identifiable information, protected health information and stored password files related to insurance billing were involved. However, the company said it does not collect Social Security numbers in the affected systems and does not store financial account or payment card data there. The total volume of stolen data has not yet been determined. AdaptHealth deemed the incident material due to the nature and potential volume of the data at risk.

3. Containment efforts and broader industry context: After detecting the intrusion, AdaptHealth disabled the compromised account, reset credentials and added access controls, while working with external forensic teams to investigate. The company said the incident has been contained and has not materially affected operations or its ability to serve patients. It is still assessing potential financial impacts, including legal and regulatory costs, and noted that cybersecurity insurance may offset some losses. The breach follows a series of recent cyberattacks affecting other medtech firms, some of which have experienced operational and financial repercussions.