OIG Says There Are Ghosts in Medicare Advantage and Medicaid Plans

By Joey Rettino – Last week, The Department of Health and Human Services’ Office of Inspector General (OIG) confirmed there are ghosts lurking inside Big Insurance’s Medicare Advantage and Medicaid plans. Not the kind that rattle chains on Halloween but “ghost providers” – the psychiatrists, therapists and other behavioral health providers listed in insurance companies’ taxpayer-funded directories even though those providers aren’t actually available to see patients. These “ghost providers,” as the OIG calls them, make networks look robust on paper but curse patients to spend weeks calling disconnected numbers or showing up at practices where no one accepts their plan. Read Full Article...

HVBA Article Summary

1. Prevalence of Inactive Providers: The OIG report found that a significant portion of behavioral health providers listed in Medicare Advantage and Medicaid directories are not actually available to patients. This practice inflates the perceived size of provider networks, making it difficult for enrollees to find real, accessible care. As a result, patients may waste time and effort contacting providers who are not accepting new patients or are no longer participating in the network.

2. Financial Incentives and Oversight Challenges: Insurers receive fixed, advance payments from the government to cover enrollees, regardless of how much care is actually delivered. This capitation model can create incentives for insurers to limit access to care, as unspent funds contribute to profits. The OIG highlighted that current federal oversight often relies on insurer-reported data, and recommended using actual billing data and establishing a national provider directory to improve accountability.

3. Impact on Mental Health Access: Many Americans enrolled in Medicare and Medicaid plans have substantial behavioral health needs, yet limited access to in-network providers exacerbates barriers to care. The shortage of available providers can lead to untreated mental health conditions, with potential consequences for physical health and increased hospitalizations. The persistence of “ghost networks” undermines efforts to address mental health disparities in vulnerable populations.

How the Expiration of ACA Tax Credits Will Impact Commercial Insurance, Per a Cigna Exec

By Marissa Plescia – The government shutdown is still underway, and a key sticking point of this shutdown is the expiration of the Affordable Care Act’s enhanced premium tax credits at the end of the year. These were introduced in 2021 and lowered monthly premiums for those who buy coverage on the marketplaces. Democratic lawmakers are calling for an extension of the tax credits, while Republicans have been more reluctant. It’s estimated that if the tax credits expire, ACA Marketplace premiums will more than double on average next year. Read Full Article...

HVBA Article Summary

1. Broader Impact Beyond Marketplace Enrollees: The expiration of enhanced ACA premium tax credits will not only affect those purchasing insurance on the marketplaces but could also have financial consequences for employer-sponsored and commercial insurance populations. Experts warn that premiums for these groups may rise as insurers seek to offset the effects of losing the exchange credits. This could make health coverage less affordable for a wider segment of Americans.

2. Potential Increase in Uninsured and Uncompensated Care: If the tax credits are not extended, more Americans may lose their health coverage, leading to an increase in uninsured individuals. Healthcare providers may then be required to deliver more care that is not reimbursed, putting additional financial strain on provider systems. This situation could exacerbate existing access issues for patients and further stress the healthcare infrastructure.

3. Spillover Effect on Commercial Insurance Premiums: Industry leaders suggest that the loss of government-funded support, such as ACA tax credits or Medicaid cuts, often results in hospitals and providers charging commercial insurance plans more to compensate for lost revenue. This dynamic could lead to a cycle where commercial market premiums continue to rise, making it increasingly difficult for employers and individuals to manage healthcare costs. The assumption that commercial markets can continually absorb these increases is being challenged by both insurers and employers.

Broken No Surprises Act arbitration drives up premiums

By Kristen Smithberg – Nearly 40% of disputes submitted to the federal Independent Dispute Resolution (IDR) process in 2024 were identified as ineligible, yet many still advanced through arbitration—forcing employers and health plans to pay unnecessary or excessive claims, according to a new survey from America’s Health Insurance Plans (AHIP) and the Blue Cross Blue Shield Association (BCBSA). The report cites a growing number of out-of-network claims from certain providers and private-equity-backed firms as one of the most persistent abuses of the IDR system. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. High Rate of Ineligible Claims Advancing in Arbitration: Nearly 40% of disputes submitted to the IDR process in 2024 were identified as ineligible, but only 17% were ultimately deemed ineligible by IDR entities. This means that over half of the ineligible claims still proceeded to binding payment decisions, causing employers and health plans to pay unnecessary or excessive claims. This inefficiency contributes to increased costs in the healthcare system.

2. Misuse Driven by Certain Providers and Private-Equity Firms: The report highlights that a growing number of out-of-network claims from specific providers, particularly private-equity-backed organizations, are a persistent abuse of the IDR system. These entities drive a disproportionate volume of disputes, with payments averaging 400% above contracted rates, significantly inflating healthcare costs and premiums for everyone.

3. Call for Policy Reforms to Restore Balance and Transparency: AHIP and BCBSA urge policymakers to address misaligned incentives that allow unnecessary disputes to advance through the IDR process. They advocate for increased accountability and oversight to reduce wasteful spending, which the Georgetown University Center on Health Insurance Reforms estimates at around $5 billion since the system's inception. These reforms aim to protect employers, health plans, and ultimately consumers from rising premiums caused by arbitration abuses.

Insurers most often blamed for medical debt, but providers trusted to protect patient interests: survey

By Dave Muoio – U.S. consumers across the political spectrum are largely in favor of new legal protections against medical debt, and the majority are laying blame at the feet of the insurance industry rather than other healthcare players like hospitals or drugmakers, according to a new national survey. The poll of 1,319 2024 general election voters, fielded between Aug. 21 and Sept. 2, 2025, found about 35% currently owed money or have debts due to medical and dental expenses. Read Full Article...

HVBA Article Summary

1. Insurance Companies Receive Majority of Blame for Medical Debt: According to the survey, 63% of respondents identified insurance companies as the main party responsible for medical debt, with this view held by 70% of Democrats, 62% of Republicans, and 59% of independents. In contrast, only 12% blamed pharmaceutical companies, 9% hospitals, and 2% doctors. This widespread attribution of blame to insurers reflects a broad dissatisfaction with the insurance industry’s role in protecting consumers from healthcare-related financial burdens.

2. Strong Bipartisan Support for Medical Debt Protections: The survey revealed overwhelming support for state-level policies aimed at alleviating medical debt, with 94% favoring limits on medical debt interest rates and 90% supporting restrictions on collection agencies' ability to seize property. Additionally, 89% backed requirements for hospitals to use a uniform application for financial assistance, and 81% supported banning medical debt from credit reports. These high approval rates were consistent across party lines, indicating that medical debt reform is a unifying issue for voters.

3. Trust in Providers Remains High Despite Systemic Frustrations: While only 34% of respondents expressed trust in health insurance companies, a much larger proportion—85%—said they somewhat or very much trusted doctors and other providers to act in their best interests, and 78% trusted hospitals. In comparison, trust was lower for drug companies (32%), private equity firms (29%), and large corporate-run health systems (26%). These findings suggest that, despite frustrations with the broader healthcare system, patients continue to place significant trust in individual providers and hospitals.

12 states with the worst disability employment ratios

By Allison Bell – The U.S. economy depends on people being able to work. But employers in some states face a strong headwind: Many people ages 16 through 64 face conditions, such as blindness, deafness or an inability to walk, that could interfere with their ability to work in many workplaces with use of assistive technology or other accommodations. Managers of the American Community Survey, a major U.S. Census Bureau survey program, measure the impact of disability on the labor force by looking at the percentage of people ages 16 through 64 with a disability who are employed. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Employment Ratio Improvement: The employment ratio for working-age people with disabilities has improved from 39.4% in 2019 to 46.9% in 2024. This increase may be attributed to a stronger job market and the rise of work-from-home opportunities, which can better accommodate individuals with disabilities. Despite this progress, the employment ratio for people with disabilities remains significantly lower than the 64.9% employment ratio for all working-age people.

2. State Variations and Challenges: Some states have particularly low employment ratios for working-age adults with disabilities, with fewer than half employed in certain areas. This indicates regional disparities in employment opportunities and accessibility for disabled individuals. Employers in states with higher disability rates face challenges both in preventing disability and in accommodating workers with physical challenges who want to remain in or enter the workforce.

3. Importance of Accommodations: The article highlights the role of assistive technology and workplace accommodations in enabling people with disabilities to work. The surge in accommodation requests by over 21% underscores the growing need for employers to focus on accessibility. Providing appropriate accommodations can help tap into a motivated workforce and support economic participation among people with disabilities.

Why more employers are embracing total benefits consulting

By Sean Rabinowitz and Thomas Gahan – As the lines between financial wellness and physical well-being continue to blur in today's workplace, employers are rethinking how they deliver employee benefits. The result is a growing shift toward the total benefits consulting (TBC) model, an approach that unites all aspects of benefits strategy under one integrated advisory team. The TBC model provides an employer with a single team of consultants, with team members having specialty backgrounds in each aspect of an organization's employee benefit plan. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Fragmented benefits management is increasingly inefficient: Managing retirement plans, health insurance and wellness initiatives through separate vendors creates communication gaps, higher administrative workloads and fewer opportunities to align benefits with business goals. Without a unified strategy, HR teams juggle multiple relationships and timelines, while employees navigate disconnected programs that can feel confusing rather than empowering.

2. Centralized consulting enhances education, engagement and compliance: A single consultant model enables tailored communication and training, boosting employee understanding of their benefits — the article states that employees who understand and appreciate their benefits are 60% more likely to stay with their employer over the next year. It also notes that organizations with highly engaged employees have 43% lower turnover, and indicates that the average settlement for non‑compliance under Employee Retirement Income Security Act (ERISA) in 2024 topped $4.6 million—highlighting high compliance stakes.

3. Efficiency gains benefit both HR and the organization: Working with one benefits consultant reduces duplication, simplifies administration and coordinates strategy. According to the article, a “total benefits” approach can nearly cut in half the time an HR professional spends administering plans — e.g., if HR spends on average two hours per week, that equates to almost 100 hours annually returned per HR professional. This efficiency is appealing not only to large corporations but increasingly to midsize employers seeking smarter ways to attract and retain talent in a competitive labor market.

Costco now offers GLP-1s, but that won’t have a major market shift, experts say

By Cassie McGrath – Wholesale giant Costco entered the GLP-1 chat earlier this month when it announced it would sell Danish biotech Novo Nordisk’s weight loss medication through its pharmacies. As of Oct. 3, Costco will offer Wegovy and Ozempic for $499 per month, a discount off list prices of $1,349.02 and $997.58, respectively, for patients paying out of pocket. The wholesaler’s announcement is the latest partnership in Novo Nordisk’s strategy to offer more affordable options for its diabetes and weight loss medications. Read Full Article...

HVBA Article Summary

1. Limited Market Impact Expected: Although Costco's entry into the GLP-1 market is notable, experts believe it will not significantly disrupt the market. The $499 monthly price for medications like Wegovy and Ozempic is already available at other major pharmacies and through Novo Nordisk's own direct-to-consumer channels. As a result, the move is seen as an extension of existing pricing strategies rather than a game-changing development.

2. Potential for Increased Awareness: Costco's large and loyal customer base could help raise awareness about more affordable GLP-1 options. With 81 million members, the visibility of these medications in Costco pharmacies may prompt more people to consider them, especially those who may not have been aware of similar offers elsewhere. However, the price point remains high for many, limiting broader accessibility.

3. Competitive Pressures and Regulatory Scrutiny: The GLP-1 market is becoming more competitive as companies like Novo Nordisk and Eli Lilly lower prices to compete with compounding pharmacies and telehealth providers. Some compounding companies, such as Hims & Hers, offer similar medications at much lower prices, though these are not always FDA-approved. The FDA is reportedly investigating the advertising practices of these compounding companies, which could affect the market landscape in the future.

Prevention Has a Branding Problem

By Beata Pasek, EdD, MPPM – In healthcare, prevention is too often treated as optional -- an add-on when budgets allow. But prevention isn't a luxury. It is the most economically sound, clinically effective, and ethically aligned path forward. So, why hasn't the prevention paradigm shifted? The Economic Lens Isn't Enough Read Full Article...

HVBA Article Summary

1. Prevention is undervalued when viewed only through economic benefits: Despite billions spent annually on preventable complications and the long-term costs of chronic conditions, prevention efforts are often the first to be cut when budgets tighten. Funding for prevention programs, including federal initiatives, has been redirected or rolled back, showing that cost-saving arguments alone fail to secure sustained investment in prevention. This economic framing does not align with the healthcare system's reward structure, which favors acute and high-cost interventions over preventive care.

2. Ethical considerations provide a stronger rationale for prevention: The article argues that prevention should be framed as a moral imperative rather than just a financial strategy. When healthcare systems fail to reimburse or prioritize preventive measures like nutrition counseling or pediatric prevention, they effectively accept preventable harm and unnecessary suffering. This ethical gap highlights a misalignment between what improves patient outcomes and what the system rewards, emphasizing the need for leadership to realign incentives to support prevention as a core healthcare value.

3. Leadership and systemic change are essential to elevate prevention: Healthcare leaders play a crucial role in shifting the culture to value prevention by funding it as a core obligation and empowering clinicians to provide preventive care without fear of non-reimbursement. Realigning incentives to reward and measure prevention success can create sustainable conditions for long-term health improvements. Ethical leadership that prioritizes prevention signals a commitment to healthcare integrity and can drive true systemic change beyond short-term financial metrics.