Disputes under No Surprises Act surge 119% as employer plans face hikes

By Allison Bell – Employers are facing a big increase in the volume of health care payment fights flowing through the No Surprises Act dispute resolution system — a preliminary analysis shows employer plans that lose may pay more than 20 times, or even 40 times, as much as the typical in-network rate for care. Private-sector plans were involved in 524,052 of the disputes reported to the Centers for Medicare & Medicaid Services in the second quarter of 2025, according to newly posted CMS data. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Disputes Under the No Surprises Act Increased Significantly: The number of billing disputes rose 119%, increasing from 238,932 in the second quarter of 2024 to a much higher total in the second quarter of 2025. These disputes largely involve emergency care at out-of-network hospitals, out-of-network providers working within in-network hospitals, and air ambulance services. Disputes grew for both fully insured employer plans (up 111% to 43,745) and self-insured employer plans (up 121% to 195,187).

2. Payment Outcomes Often Exceed Typical In-Network Rates: CMS dispute resolution data shows that final payments are measured relative to the qualifying payment amount (QPA), which represents typical in-network rates in a given area. A preliminary analysis of one million Q2 2025 records found that fully insured employer plans paid an average of 173% of the QPA, while self-insured plans that won disputes paid about 185% of the QPA. When plans lost disputes, payments were much higher, averaging 23 times the QPA for self-insured plans and 44 times the QPA for fully insured plans.

3. Policy Debate Over the Dispute Resolution System Continues: Congress created the No Surprises Act arbitration system to remove patients from billing conflicts between providers and insurers. Health plans argue that they frequently lose disputes and that the awarded payments are substantially higher than in-network reimbursement rates. Some patient advocacy and employer benefits groups are urging Congress to revise the system, saying the high payments may contribute to rising health care costs.

With CVS’s Vertical Empire Under Threat in Tennessee, the Company Threatens to Leave

By Wendell Potter – Most people think of CVS as a drug store, but it’s a lot more than that. Not only does it operate more than 9,000 retail stores – 134 in my home state of Tennessee – it also owns Aetna health plans. But as big as those divisions of this megaconglomerate are, it actually gets more revenue from a subsidiary that is far less well known: Caremark. CVS Caremark is a pharmacy benefit manager, one of the three biggest in the country, along with Cigna’s Express Scripts and UnitedHealth’s Optum Rx. Together these giant middlemen control 80% of the middle part of the pharmacy supply chain. Read Full Article...

HVBA Article Summary

1. PBMs and Market Concentration in Prescription Drug Management: Pharmacy Benefit Managers (PBMs) play a central role in determining medication access and patient out-of-pocket costs in the United States. Large healthcare conglomerates such as CVS operate vertically integrated systems that include a health insurer, a PBM, and retail pharmacy chains, a structure that has contributed to rapid corporate growth and higher placement on the Fortune 500. In 2023, CVS, Cigna, and UnitedHealth collectively managed nearly 79% of prescription drug claims, raising concerns among some policymakers and pharmacists about market concentration and its effects on independent pharmacies.

2. Tennessee Pharmacy Closures and Proposed PBM–Pharmacy Separation: Tennessee lawmakers have introduced Senate Bill 2040, which would prohibit a company from owning both a pharmacy and a PBM simultaneously to address potential conflicts of interest tied to vertical integration. The bill would require affected companies to divest or restructure by January 1, 2028, rather than mandating pharmacy closures. The proposal comes amid significant industry changes in the state, where 815 pharmacies have closed over the past decade, including 163 in the last three years and 62 in 2024 alone.

3. Industry Response and Policy Debate Over PBM Practices: CVS has launched an opposition campaign, stating that the bill could lead to the closure of its 134 Tennessee stores and the loss of roughly 2,000 jobs, while the bill’s sponsors argue that the legislation only requires divestment and does not force closures. Supporters point to findings from a 2024 Tennessee Department of Commerce and Insurance audit that identified the use of spread pricing, where PBMs charge health plans more for drugs than pharmacies are reimbursed. Similar PBM ownership restrictions passed in Arkansas in 2025 but were temporarily blocked by a federal judge over Commerce Clause concerns, suggesting Tennessee could face comparable legal challenges if the bill advances.

Congress must fix the No Surprises Act before it bankrupts patients and employers

By James Gelfand and Patricia Kelmar – Five years ago, President Trump delivered a historic victory for American patients when he signed the No Surprises Act (NSA) into law. The promise of this legislation was simple: Families would be protected from financial ruin caused by virtually unavoidable surprise medical bills. For patients’ immediate bills, the law has been a resounding success. They are no longer subject to eye-popping surprise bills arriving in the mail. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Independent Dispute Resolution System Under the No Surprises Act: The No Surprises Act (NSA) created the Independent Dispute Resolution (IDR) process to resolve payment disputes between insurers and out-of-network providers when negotiations fail. Under this system, both parties submit payment offers and a government-approved arbitrator selects one as the final binding payment amount. The process was intended to function as a limited, last-resort mechanism to settle disputes without affecting overall health care costs. It was originally expected to be used only in relatively rare cases where negotiations between insurers and providers could not reach an agreement.

2. High Volume of Arbitration Cases and Payment Outcomes: Recent data shows that the IDR system is being used more frequently than initially expected. In the first half of 2024, approximately 610,000 disputes were filed, contributing to about $5 billion in IDR-related costs between 2022 and 2024. A small number of provider groups initiated a large share of cases, and arbitration decisions often resulted in payments significantly higher than standard in-network rates. These outcomes have raised questions among stakeholders about whether the process is influencing payment levels across the broader health care system.

3. Policy Concerns and Calls for Oversight: Some stakeholders argue that the current IDR process allows certain providers to benefit from arbitration outcomes that exceed market payment levels, potentially contributing to higher premiums. Reports also indicate that a portion of submitted disputes may not meet eligibility requirements under the NSA. Policymakers and advocacy groups have proposed reforms such as stronger enforcement of eligibility rules, increased transparency in arbitrator decisions, and clearer regulatory guidance to improve oversight of the system. Several lawmakers and stakeholder groups have also called on regulators to review how the arbitration system is implemented to ensure it operates as originally intended.

As Ozempic costs fall, demand for weight-loss drugs is set to surge

By Jimmy Nesbitt – Companies are expecting a surge in demand for weight loss drugs after one of the world's leading pharmaceutical giants announced a price cut of up to 50% starting next year. Novo Nordisk plans to reduce the list prices of Ozempic and Wegovy to $675 per month beginning Jan. 1, 2027, down from roughly $935 and about $1,350 per month, respectively, though many patients pay less depending on insurance coverage and rebates. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Significant Price Reductions Expected to Drive Demand: Novo Nordisk's decision to cut the prices of Ozempic and Wegovy by up to 50% is anticipated to make these weight-loss drugs more accessible to a broader population. As a result, employers are preparing for a notable increase in employee demand for GLP-1 medications. This shift could have a substantial impact on benefits planning and overall healthcare costs for organizations.

2. Employers Must Adapt Benefits Strategies: With the anticipated rise in utilization of GLP-1 drugs, employers are encouraged to rethink their benefits design and cost management strategies. Experts suggest that employers should not only consider the direct costs of these medications but also evaluate alternative coverage models, such as lifestyle or limited benefits, to balance access and affordability. Proactive planning will be essential to ensure both employee health and sustainable benefits spending.

3. Data-Driven Decision Making Is Crucial: To effectively manage the evolving landscape of weight-loss drug coverage, benefit teams are advised to closely monitor utilization data, program costs, and employee behaviors. Understanding the specific needs of their workforce and the financial implications of coverage choices will help employers make informed decisions. Collaborating with consultants and leveraging centers of excellence can further support the development of effective, long-term strategies for GLP-1 drug benefits.

AI chatbot use for health information up 16% from 2024: Rock Health survey

By Cailey Gleeson – Consumers are increasingly turning to artificial intelligence chatbots for health information, a new report from Rock Health says. Thirty-two percent of respondents in the 2025 Consumer Adoption of Digital Health Survey reported using AI chatbots to find health information, up from 16% in 2024. Researchers at the digital health venture fund polled 8,000 U.S. Census-matched adults in December 2025 on their attitudes and behaviors toward digital health tools and care. The survey was conducted before AI platforms introduced their own healthcare chatbot offerings, such as Microsoft’s Copilot Health and OpenAI’s ChatGPT Health. Read Full Article...

HVBA Article Summary

1. Significant Growth in AI Chatbot Use: The use of AI chatbots for health information has doubled within a year, reflecting a rapid shift in consumer behavior. This increase occurred even before major tech companies launched dedicated healthcare chatbot products. The trend suggests that consumers are becoming more comfortable with digital tools for managing their health needs.

2. Changing Patterns in Health Information Seeking: AI chatbots are now being used for a variety of health-related tasks, including searching for treatment options, preparing questions for medical appointments, and managing mental health. After interacting with chatbots, users often take further actions such as consulting healthcare providers, changing health behaviors, or discussing findings with others. This indicates that chatbots are influencing not just information gathering but also subsequent health decisions.

3. Demographic Differences and Evolving Physician Roles: Younger generations and racial or ethnic minorities are more likely to use AI chatbots for health information compared to older adults. The report notes that as chatbot use becomes more widespread, the physician’s role may evolve from being the primary source of information to acting as a guide or advisor. Researchers highlight ongoing concerns about clinical accuracy and the need to balance innovation with standards of care, privacy, and safety.

NAMI: 1 in 4 workers considered quitting over their job’s toll on their mental health

By Ginger Christ – A little more than half of employees think their company prioritizes their mental health, but just over a quarter of managers say they’ve received training on how to address mental health at work, NAMI found. On top of that, less than a third of employees surveyed said they have had any mental health-related training at work. Yet the majority of workers said it would be helpful to have training on mental health conditions, on how to respond to a mental health crisis and on burnout management. Read Full Article...

HVBA Article Summary

1. Workplace Mental Health Training Shows Positive Impact: Employees at companies that provide mental health training report feeling more supported by leadership and less concerned about stigma surrounding mental health discussions at work. The findings suggest that training programs can help normalize conversations about mental health and encourage employees to view it as an appropriate workplace topic. However, barriers such as stigma and fears of retaliation or reduced career opportunities still remain.

2. Workplace Loneliness Linked to Distributed Work and AI Adoption: Reports indicate that loneliness remains a widespread issue among workers, particularly in distributed or remote work environments. More than half of U.S. workers say they experience loneliness, according to research from The Cigna Group. Additional findings suggest that knowledge workers who increasingly use artificial intelligence report higher levels of workplace loneliness and a stronger desire for human connection.

3. Mental Health Strain Contributing to Burnout and Turnover Consideration: Survey data from the National Alliance on Mental Illness shows that workplace stress continues to affect employee mental health. A quarter of workers reported considering quitting their job due to its impact on their mental health, while more than half said they feel burned out. The findings also suggest that workplace resources, training, and open dialogue about mental health may help reduce stigma and support employee well-being.

American healthcare: High $26,000 premiums and diminishing returns

By Susan Rupe – The majority of Americans receive their health care from employer-sponsored plans. “Employer-sponsored coverage isn’t one small part of the health care system – it is the American health care system,” said Dan Aronowitz, assistant secretary of labor and head of the Employee Benefits Security Administration. He provided a report on employer health policy priorities during the AHIP Medicare, Medicaid, Duals and Commercial Markets Forum in Washington. With premiums for families covered under employer plans exceeding $26,000 annually, Aronowitz said, “We are spending more on health care and getting less in return.” Read Full Article...

HVBA Article Summary

1. The Great Healthcare Plan Framework: The Trump administration introduced “The Great Healthcare Plan,” which is structured around four broad policy pillars rather than a detailed legislative bill. The plan focuses on lowering prescription drug prices, reducing health insurance premiums, increasing accountability for insurers, and expanding price transparency across the health system. Supporters say the approach is intended to return more control over health care decisions to employers and workers while aiming to reduce overall costs.

2. Policies Target Drug Prices and Insurance Costs: Proposed initiatives include codifying “most-favored-nation” drug pricing tied to prices in comparable countries, creating voluntary pricing agreements with drug manufacturers, expanding over-the-counter access for certain medications, and launching a federal price-comparison platform called TrumpRx. The plan also proposes redirecting certain insurer subsidy payments directly to consumers so they can purchase coverage of their choice. Additional efforts target pharmacy benefit manager practices that the administration says contribute to higher prescription drug costs.

3. Transparency and Mental Health Policy Efforts: The Department of Labor has proposed a rule requiring pharmacy benefit managers and related consultants to disclose compensation connected to self-insured employer health plans to increase transparency. Officials say the rule is intended to provide clearer insight into prescription drug pricing structures. At the same time, the Employee Benefits Security Administration is working to enforce mental health parity requirements so mental health benefits are treated comparably to other medical benefits while maintaining manageable compliance expectations for employers and insurers.