Don’t Just Block Ads for Pills – Block Medicare Advantage Ads, Too

By Wendell Potter – The Trump administration announced last week it plans to crack down on prescription drug advertising. In reporting on the news, the New York Times quoted former Food and Drug Administration David Kessler as saying that what the administration is proposing “would in essence remove direct-to-consumer advertising from television.” Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Call for Transparency in Health Advertising: Health and Human Services Secretary Robert F. Kennedy Jr. announced an initiative aimed at stopping deceptive pharmaceutical advertising by requiring drug companies to disclose all essential safety information in their promotions. The effort is framed as a public protection measure to ensure consumers are not misled about potential risks.

2. Criticism of Medicare Advantage (MA) Advertising Practices: The article draws attention to misleading advertisements by Medicare Advantage plans, particularly during the annual open enrollment period. It highlights how these ads often present an overly positive image—focusing on "free" benefits—while failing to disclose critical downsides such as restricted provider networks, prior authorization delays, and denial of medically necessary care, which can have serious or even fatal consequences.

3. Demand for Regulatory Parity and Consumer Protection: The author advocates for holding Medicare Advantage insurers to the same truth-in-advertising standards proposed for drug companies. There is a strong push for the government and Congress to take swift action to ensure MA ads cannot omit important facts. The goal is to better inform seniors and people with disabilities, helping them make safer, more informed choices about their healthcare coverage.

UnitedHealth Group increases lobbying of Trump administration

By Alan Goforth – UnitedHealth Group has stepped up its lobbying efforts targeting the Trump administration as it seeks to rebound from numerous lawsuits and regulatory issues that have caused its market value to decline by 40% since April. The company’s disclosures show that it spent $7.7 million on lobbying during the first half of 2025, which is about twice what it spent during the same period last year, the Wall Street Journal reported on Monday. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Increased Lobbying Amid Investigations: UnitedHealth has intensified its lobbying efforts, targeting officials with connections to the Trump administration. This includes meetings with senior figures at the Department of Justice, the White House, and the Centers for Medicare & Medicaid Services, amid reports of a federal criminal investigation into its Medicare business. While unusual for a company under early-stage criminal scrutiny, these meetings aimed to address regulatory issues, not directly influence investigations.

2. Focus on Medicare Policy and Industry Impact: UnitedHealth executives, including CEO Stephen Hemsley, met with various policymakers to discuss Medicare billing rules and supplemental benefit policies, especially in light of regulatory changes under the Biden administration. These changes have negatively affected the company's Medicare Advantage business, which generated over $100 billion in revenue in 2023.

3. Public Position on Lobbying Justified by Health Policy Influence: UnitedHealth defended its lobbying campaign as standard practice, emphasizing the importance of engaging with government bodies to shape public policy and improve healthcare affordability. Government officials, including a White House spokesperson, also framed such meetings as routine interactions with insurers intended to support health reform goals.

Senator joins call asking Cigna to rescind new downcoding policy

By Andrew Cass – Sen. Richard Blumenthal is urging Cigna to rescind a new policy he said will create “onerous administrative burdens for physicians, needlessly raises costs for healthcare providers and jeopardizes patient care.” Beginning Oct. 1, Cigna’s new Evaluation and Management Coding Accuracy policy will review CPT evaluation and management codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy. Some services may be adjusted by one level when guidelines are not met. Read Full Article...

HVBA Article Summary

1. Cigna's New Reimbursement Policy for E/M Codes: Cigna Healthcare is introducing a new policy targeting a small group (around 3%) of in-network physicians who consistently bill higher-level Evaluation and Management (E/M) codes than their peers. These claims will undergo individual review, and payments may be reduced by one level to align with American Medical Association (AMA) guidelines. Physicians will retain the right to appeal decisions.

2. Concerns Over Administrative Burden and Impact on Small Practices: Critics, including Senator Blumenthal, argue that the policy could disproportionately affect small medical practices by requiring written appeals for each downcoded claim. They believe this will consume time and resources, potentially jeopardizing patient care and the financial stability of physicians.

3. Calls for Alternative Approaches by Medical Associations: Medical associations in California and Texas have called for the policy to be rescinded. They suggest that rather than enforcing automatic payment reductions, Cigna should prioritize educational efforts targeting providers with unusual coding patterns, to reduce errors without increasing administrative workloads.

Democrats threaten shutdown to avert major Obamacare premium hike

By Erik Wasson and Steven T. Dennis – Democrats are threatening to block a bill needed to avert an Oct. 1 US government shutdown unless Republicans agree to stop a sharp spike in Obamacare health insurance premiums or meet other demands by the minority party. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Obamacare Subsidy Extension Faces Political Deadlock: The enhanced Obamacare insurance subsidies, which have helped millions of Americans afford lower premiums, are scheduled to expire on January 1. Democrats are pushing to extend these subsidies through the upcoming stopgap funding bill, seeing it as their best legislative window. However, their influence is limited—especially in the House, where Republicans maintain a narrow majority and can pass a bill without Democratic support.

2. Partisan Divide Over Policy Add-ons in Funding Bill: A sharp disagreement exists between Democrats and Republicans over whether the funding bill should include policy changes. Republican leaders, including Senate Majority Leader John Thune, are demanding a “clean” continuing resolution without add-ons like the subsidy extension. In contrast, Democratic leaders such as Chuck Schumer and Hakeem Jeffries have criticized this approach, arguing for the inclusion of health-related provisions, though they haven’t fully committed to blocking the bill.

3. Internal GOP Tensions Over Health Subsidies: Within the Republican Party, there is growing division over the proposed extension of the subsidies. Fiscal conservatives argue the cost—estimated at $24 billion for one year—is too high and the benefits too broad, extending to families well above the poverty line. However, some moderate Republicans in competitive districts worry that failing to extend the subsidies could lead to insurance premium hikes of up to 75%, making it a potent election issue heading into the 2026 midterms.

FTC warns about non-compete agreements with doctors, nurses

By Ron Southwick – Federal regulators are warning healthcare organizations to take a close look at their non-compete agreements to be sure they aren’t violating any laws. The Federal Trade Commission also says it will be watching closely, and is ready to act if it finds companies are putting unreasonable language in those agreements. Read Full Article...

HVBA Article Summary

1. FTC Scrutiny on Non-Compete Agreements in Healthcare: The Federal Trade Commission (FTC), led by Chairman Andrew N. Ferguson, is increasing oversight of non-compete agreements in the healthcare sector. Letters have been sent to healthcare employers and staffing agencies, emphasizing the need to ensure these agreements comply with federal antitrust laws, especially where they affect doctors, nurses, and other medical professionals.

2. Concerns Over Impact on Patient Care and Physician Mobility: The FTC expressed particular concern that non-compete clauses may restrict healthcare access in rural areas and limit job mobility for physicians. Organizations like the American Medical Association and the American College of Emergency Physicians argue that such agreements hinder career progression and patient choice, disproportionately affecting young or early-career doctors.

3. Regulatory and Legal Tensions Around Non-Competes: While the Biden administration attempted to ban most non-compete agreements, a federal court ruling in August 2024 blocked the FTC from enforcing that regulation. The FTC chose not to appeal but has maintained it will continue to aggressively enforce existing antitrust laws. This reflects an ongoing debate between healthcare organizations defending non-competes for proprietary protection and regulatory bodies concerned about their broader market and labor effects.

The No Surprises Act Doesn’t End Balance Billing – It Turbocharges It

By RiskManagers.us™ – The No Surprises Act (NSA) doesn’t end balance billing. It simply passes the liability from Joe Sixpack to deep pocketed plan sponsors. The sad news is………the Joe Sixpack’s out there end up paying for it all anyway in the form of higher insurance premiums. Plan sponsors must recognize their NSA risk can be significant with a tail exposure extending well beyond dates of service. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. The IDR Process Has Generated Substantial Financial Burdens: The Independent Dispute Resolution (IDR) process, part of the No Surprises Act, has generated over $5 billion in total costs through the end of 2024. These costs stem from a combination of administrative fees, internal administrative burdens for providers and insurers, and higher-than-anticipated payment determinations. The volume of disputes—over 3.3 million filed—far exceeded initial federal estimates, driving both direct and indirect spending increases, which could lead to higher premiums and overall health system costs.

2. High Dispute Volume and Delays Undermine Efficiency: Despite federal efforts to encourage pre-IDR negotiations, a large and growing number of disputes are proceeding through the formal process, with nearly 500,000 cases still pending as of May 2025. The IDR process is failing to meet its 30-day statutory timeline, with median determination times reaching 81 days. This backlog and delay are largely driven by a concentration of filings from a small number of private equity-backed provider organizations, such as Radiology Partners and Team Health.

3. Providers Prevail Frequently, With High Awarded Payments: Providers have been winning the vast majority of disputes—85% in 2024—and are often awarded payments significantly higher than typical in-network rates. The median payment was 445% of the Qualifying Payment Amount (QPA) in 2024, and even higher in some cases (e.g., 934% for disputes involving HaloMD). In contrast, plans that win receive much smaller awards. This outcome, coupled with heavy usage by a few dominant providers, raises questions about the impact of IDR outcomes on network negotiation dynamics, long-term system costs, and the need for policy reform to improve transparency and eligibility screening.

Cigna's Evernorth, UnitedHealth's OptumRx, other PBMs face insulin lawsuits setback

By Allison Bell – A federal judge in New Jersey last week issued a batch of more than 30 rulings impacting ongoing lawsuits regarding the cost of insulin. U.S. District Judge Brian Martinotti issued one ruling that rejects insulin manufacturers' motions to dismiss litigation, another, involving the state of Montana, allows plaintiffs to move ahead with conspiracy allegations against PBMs, and a third, involving the state of Illinois, lets Illinois move ahead with allegations that PBMs and insulin makers deceived insulin buyers and were unfair to insulin buyers. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Mixed Rulings on Legal Claims: A federal judge ruled that employers with self-insured health plans cannot proceed with racketeering claims against insulin manufacturers, but may continue with common-law fraud and conspiracy claims. These decisions apply to a broad range of defendants, including major pharmaceutical companies and pharmacy benefit managers (PBMs) such as Cigna's Evernorth, CVS Health, and UnitedHealth.

2. Discovery Process Moving Forward: Plaintiffs—including states, self-insured employers, and other payers—are allowed to move forward with discovery against the defendants. The court found that, assuming the plaintiffs' allegations are true, their claims were substantial enough to proceed to the next stage, particularly in raising concerns about anti-competitive behavior and artificially high insulin prices.

3. Allegations of Price Manipulation: The lawsuits allege that pharmaceutical companies and PBMs colluded to keep insulin prices high, making the medication less accessible to patients. While PBMs and manufacturers argue they have worked to make insulin affordable, the judge highlighted that the plaintiffs described behaviors—such as stifling competition and raising prices—that could result in significant harm to consumers.