‘A missed opportunity’: Payers lash out against surprise billing final rule

By Rebecca Pifer Parduhn – On Thursday, the Trump administration finalized a widely supported rule addressing shortcomings in the system through which providers and payers settle disputes over surprise medical bills. But insurers think regulators should have done a lot more. Payers are saying the Trump administration missed the mark by not cracking down on alleged provider abuse of the dispute resolution process set up by the No Surprises Act, a watershed consumer protection law passed in 2020 to shield consumers from surprise medical bills. No Surprises has largely been successful in that goal, preventing millions of Americans from being hit with unexpected out-of-network charges. Read Full Article...

HVBA Article Summary

1. IDR Process Drives Higher Provider Payments: The article highlights concerns that the No Surprises Act's Independent Dispute Resolution (IDR) process has evolved into a significant source of increased payments for some providers. Providers filed approximately 1.2 million arbitration disputes in the first half of 2025 alone, far exceeding original government projections. Critics argue that frequent provider victories and awards often exceeding in-network rates by three to four times have created incentives for extensive use of the arbitration system.

2. Payers Raise Concerns About Arbitration Incentives and Costs: Insurers, employers, and unions argue that flaws in the arbitration process may encourage the submission of ineligible disputes and contribute to disproportionately high provider awards. They contend that arbitrators may face incentives to accept more cases because providers initiate the vast majority of disputes, while decisions are final and cannot be appealed. These stakeholders warn that higher arbitration payouts can increase healthcare costs, which may ultimately be reflected in insurance premiums and employer-sponsored health plan expenses.

3. New Rule Introduces Incremental Reforms with Broad Support: The final rule aims to improve the IDR process by reducing ineligible disputes, standardizing communication between payers and providers, and enhancing the federal arbitration portal. While payer groups sought stronger oversight of arbitrators, including audits and conflict-of-interest reviews, many stakeholders view the changes as a positive step toward greater efficiency and transparency. Provider organizations have also welcomed portions of the rule, particularly measures that lower filing costs and improve access to the arbitration process for smaller medical practices.

Employer stop-loss could break free from state, federal health insurance rules

By Allison Bell – The Self- Insurance Protection Act bill could free employers' stop-loss insurance policies from federal health benefits rules as well as from state health benefits mandates, according to analysts at the Congressional Budget Office. Employers with self-insured health plans use stop-loss insurance to protect their plans against catastrophic losses. The SIPA bill would exclude stop-loss insurance from the definition of health insurance coverage given in the Employee Retirement Income Security Act of 1974, according to the CBO analysts. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. SIPA Bill Would Limit Regulatory Oversight of Stop-Loss Insurance: The Self-Insurance Protection Act (SIPA) would prevent states from restricting group health plans from obtaining stop-loss insurance and would exclude stop-loss policies from certain ERISA insurance-related regulations. The legislation is intended to preserve access to stop-loss coverage for self-insured employers, including smaller employers that increasingly use these arrangements. If enacted and interpreted as the Congressional Budget Office (CBO) expects, employers using stop-loss insurance would remain subject to ERISA, while stop-loss policies themselves would not be treated as health insurance coverage under ERISA.

2. Bill Addresses State Efforts to Regulate Small Self-Insured Plans: The proposal comes amid growing use of stop-loss insurance by small employers seeking to self-insure and potentially avoid some state health benefit mandates. In response, several states have implemented requirements such as minimum employer size thresholds or small-group insurance rules for stop-loss arrangements. SIPA seeks to limit states' ability to impose such restrictions while still allowing states to regulate the availability and coverage terms of stop-loss insurance.

3. Minimal Federal Budget Impact Could Aid Legislative Efforts: The CBO and Joint Committee on Taxation concluded that implementing SIPA would have little or no effect on federal spending or revenue. States would continue to oversee the solvency of stop-loss insurers, but neither states nor the U.S. Department of Labor could apply health insurance benefit mandates to stop-loss providers in the manner addressed by the bill. The measure advanced out of the House Education and Workforce Committee on a party-line vote, and its negligible budget impact could improve its prospects under congressional procedures that favor fiscally neutral legislation.

CMS grants Elevance Health a reprieve from Medicare Advantage sanctions

By Paige Minemyer – Elevance Health has earned a reprieve from potential federal sanctions on its Medicare Advantage plans. The Centers for Medicare & Medicaid Services sent a letter (PDF) to the company Friday, saying that it has completed key steps to remedy the agency's concerns. CMS was set to suspend enrollment in Elevance's MA plans on March 31 if the insurer did not comply. In March, CMS said that the company had consistently failed to use the agency's official channels to correct data on diagnostic codes found to be unsupported by medical records. Read Full Article...

HVBA Article Summary

1. CMS Temporarily Lifts Sanctions Threat: The Centers for Medicare & Medicaid Services (CMS) has paused its planned sanctions against Elevance Health's Medicare Advantage plans after the company took steps to address compliance concerns. Elevance submitted the required data through official channels and made a wire transfer for overpayments, though the exact amount was not disclosed. This action prevented the immediate suspension of new enrollments that was scheduled for March 31.

2. Ongoing Compliance Requirements Remain: Despite this reprieve, Elevance Health is still required to complete additional corrective actions by June 30 and resolve any outstanding issues by July 31 to avoid future sanctions. If these steps are not met, CMS has stated that sanctions could be implemented as early as July 1 or August 1, depending on the status of compliance. The company remains under close regulatory scrutiny until all requirements are fulfilled.

3. Background of Noncompliance and Market Impact: CMS's concerns stemmed from Elevance Health's repeated failure, since at least November 2018, to submit corrected risk adjustment data through the agency's designated electronic systems, instead using encrypted USB drives. The company revised its practices in April 2023 following federal guidance, but the issue affected claims predating that change. News of the potential sanctions previously led to a significant drop in Elevance Health's share price, highlighting the financial and reputational risks associated with regulatory noncompliance.

CHAI releases AI governance guidance for health systems

By Emily Olsen – The Coalition for Health AI released a series of governance resources this week that aim to help health systems safely roll out artificial intelligence tools. The playbooks, developed through community workshops and work groups that included more than 150 clinicians and health AI leaders, provide examples and guidance on implenting AI, including resources on setting up AI policies, managing third party developers and assessing risks. The goal is to provide a standardized, but flexible framework that health systems can use to deploy AI tools, regardless of their size or available resources, CHAI said. Founded in 2021, CHAI is a network of more than 3,000 organizations — including health systems, technology startups and patient advocacy groups — that aims to develop guidelines on responsible AI use in healthcare. Read Full Article...

HVBA Article Summary

1. Comprehensive AI Governance Resources: The Coalition for Health AI (CHAI) has released governance playbooks designed to help health systems implement artificial intelligence in a safe and responsible manner. These resources were developed with input from over 150 clinicians and AI leaders, ensuring a broad perspective on best practices. The playbooks address key areas such as policy creation, risk assessment, and third-party developer management.

2. Standardized Yet Adaptable Framework: CHAI's guidance is intended to serve as a standard framework that can be adapted by health systems of varying sizes and resource levels. The materials emphasize flexibility, allowing organizations to tailor governance structures and oversight committees to their unique needs. This approach aims to make responsible AI deployment accessible to a wide range of healthcare providers.

3. Ongoing Evolution and Sector Expansion: CHAI plans to continue refining its guidance based on feedback and the evolving landscape of AI governance. The coalition also intends to expand its playbooks to include other sectors within healthcare, such as payers. This iterative process reflects the rapid pace of AI adoption in healthcare and the need for governance frameworks to keep up with technological advancements.

Walmart, Telahealth partner to expand virtual care nationwide

By Alan Goforth – The nation's largest virtual care provider is teaming up with the nation's largest retailer. Teladoc Health announced on Thursday that its services are now available through Walmart's Better Care Services platform. The collaboration brings Teladoc Health's suite of offerings -- including virtual urgent care, dermatology and nutrition services -- to customers seeking both insured and cash-pay options. This is the latest in a series of steps the company has taken to expand access to care by integrating with established platforms. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Strategic Expansion of Virtual Care: The partnership between Walmart and Teladoc Health aims to make virtual health services more accessible to a broader population by leveraging Walmart's extensive customer base. By integrating Teladoc's offerings into Walmart's Better Care Services platform, customers can now access a range of virtual health options, including urgent care and specialty services. This move reflects a growing trend of major retailers entering the telehealth space to meet evolving consumer expectations.

2. Affordability and Convenience for Consumers: The collaboration introduces both insured and cash-pay options, with a set cash-pay price of $89 per visit for Walmart customers. This pricing structure is designed to make virtual care more affordable and transparent, potentially reducing financial barriers for those without insurance. The convenience of accessing care through a familiar retail platform may encourage more people to seek timely medical attention.

3. Implications for Employers and Workplace Benefits: The article highlights that telehealth services, such as those offered through this partnership, can benefit employers by reducing healthcare costs and improving employee productivity. Employees may experience increased job satisfaction due to the flexibility and immediacy of virtual care, which can be accessed around work schedules. As telehealth becomes more integrated into employer-sponsored health plans, it may contribute to a more positive workplace culture and help retain talent.

Judge dismisses BCBS Texas’ surprise billing lawsuit against HaloMD

By Rebecca Pifer Parduhn – The No Surprises Act has protected millions of Americans from surprise medical bills since taking effect in 2022. While the law has shielded consumers, it’s also created major headaches for insurers and providers that find themselves at odds over how to resolve out-of-network disputes, and for regulators looking to fairly referee the process. Over the last few years, providers have emerged on top in arbitration determinations from No Surprises, a process known as independent dispute resolution or IDR. The lion’s share of disputes have been settled in favor of providers — a whopping 88%, according to the most recent data — and providers are often awarded three or four times above comparable in-network rates when they win. Read Full Article...

HVBA Article Summary

1. Judicial Limits on Surprise Billing Disputes: The federal judge's dismissal of Blue Cross Blue Shield of Texas’ lawsuit against HaloMD reinforces that courts do not have the authority to overturn arbitration decisions made under the No Surprises Act. This ruling aligns with three other recent federal court decisions, collectively signaling a judicial reluctance to intervene in independent dispute resolution (IDR) outcomes. The courts have emphasized that such disputes should be resolved within the arbitration framework established by the law, not through additional litigation.

2. Provider Success and Insurer Concerns: Data shows that providers have been prevailing in the majority of No Surprises Act arbitration cases, often receiving awards significantly higher than comparable in-network rates. Insurers, including BCBS Texas, have argued that some providers and billing companies are exploiting the arbitration process to maximize payouts, leading to increased costs for payers. Despite these concerns, the courts have thus far declined to address allegations of improper awards, leaving insurers to seek other avenues for recourse.

3. Ongoing Legal and Regulatory Tensions: While several lawsuits challenging IDR outcomes have been dismissed, some cases in other states remain active, indicating that legal battles over the No Surprises Act are not fully resolved. The persistence of these disputes highlights ongoing tensions between insurers, providers, and billing intermediaries over the implementation and impact of the law. Regulatory agencies and industry stakeholders continue to grapple with balancing consumer protections against potential system abuses and escalating arbitration costs.

Lilly's Foundayo and Zepbound to gain CVS coverage, lifting sales outlook

By Max Bayer – Eli Lilly’s flagship obesity medications will be included in CVS Caremark formularies, likely boosting sales in the most competitive commercial drug market. The company announced Thursday that its oral drug Foundayo will join CVS commercial plans beginning June 1, while its injectable product Zepbound will have coverage broadened across CVS templates by Oct. 1. The expansion opens the door for more people to buy the drugs with a $25 monthly co-pay instead of higher cash-pay prices. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. CVS Expands Access to Lilly Weight-Loss Drugs: CVS Caremark added Lilly’s oral weight-loss medication as a preferred option and reinstated Zepbound as a preferred injectable alongside Wegovy. Investors responded positively, sending Lilly shares up about 4% on expectations that broader formulary access could increase utilization. The change gives Lilly greater exposure to CVS’s approximately 90 million members and may strengthen its position in both the oral and injectable obesity treatment markets.

2. Competitive Dynamics Shift Between Lilly and Novo Nordisk: Novo Nordisk’s oral Wegovy entered the market first and has maintained a lead in prescriptions, while Wegovy has also been CVS’s sole preferred injectable option for roughly a year. The addition of Lilly’s products to preferred coverage introduces greater competition, particularly for Zepbound in the injectable category. Analysts noted that the change could benefit Lilly while potentially creating a headwind for Novo, which may have previously benefited from more exclusive formulary positioning.

3. Affordability Efforts Expand Through CVS and Medicare Programs: CVS stated that ongoing negotiations with drug manufacturers are focused on improving affordability and access for members. In addition, a Medicare bridge program remains on track to launch July 1, allowing eligible participants to obtain weight-loss medications for $50 per month. Originally intended as a temporary measure, the program has been extended through 2027 due to concerns surrounding treatment costs and utilization rates.

As AI identifies more at-risk patients, health systems face a capacity challenge

By Giles Bruce – Healthcare AI solutions tout their ability to identify more at-risk patients and irregularities imperceptible to physicians, all while keeping a human in the loop. But are there enough humans to handle all this additional demand brought on by AI? That’s a question healthcare leaders are grappling with as the technology expandsacross the industry. “You don’t want to be, say, implementing something that’s going to scan every patient for a particular disease, which costs you a lot of money if you can’t do anything about it, because you don’t have the appointments downstream to actually manage that,” said Michael Pfeffer, MD, senior vice president and chief information and digital officer of Palo Alto, Calif.-based Stanford Health Care, at Becker’s 16th Annual Meeting in April. Read Full Article...

HVBA Article Summary

1. AI Increases Clinical Demand: As AI tools become more adept at identifying at-risk patients and subtle health irregularities, healthcare systems are experiencing a surge in the number of cases requiring follow-up. This increased detection can strain existing clinical resources, especially if systems are not prepared to handle the additional workload. Leaders emphasize the importance of evaluating whether there are enough staff and appointment slots to manage the influx before deploying new AI solutions.

2. Human Oversight Is Not Always Feasible: While the concept of keeping a human in the loop is often promoted as a safety measure for AI in healthcare, experts note that relying on humans to review every AI-generated alert or summary is not sustainable. Physicians are increasingly trusting AI outputs and may not have the capacity to verify each recommendation. The human role becomes most critical in situations where direct clinical intervention is required, rather than in constant algorithm monitoring.

3. Workflow Integration Is Essential: Successful implementation of AI in healthcare requires a holistic approach that considers the entire patient care workflow. Simply adding AI tools without addressing downstream processes—such as scheduling additional tests or follow-up appointments—can create bottlenecks and inefficiencies. Health systems are encouraged to assess and adjust their workflows and staffing needs in advance to ensure that AI-driven insights can be acted upon effectively.