Search the News Archive

More Than Half of Patients Report Health Insurance Denied Drugs for Chronic or Rare Diseases

"Fifty-four percent of adults covered by private plans were told by their insurer that their medication was no longer covered ... [A]lmost half of such adults said their plan referred them to a third party to help them obtain the medications ... Such [alternative funding programs (AFPs)] save employer-sponsored health plans money ... [but] can also result in delays compared to straightforward insurance coverage.... Nearly all adults -- 92% -- said they were negatively impacted by the delays.... Almost half of patients said that ultimately their medication was once again covered through their health insurance plan."

How Tech-Enabled Flexibility Is Reshaping Pharmacy Benefits

"[N]early one in three organizations are evaluating unbundled PBM models. Modular frameworks allow plan sponsors to separate individual services and choose specialized partners based on performance, value, and strategic fit. This shift brings greater control and agility, both of which are often limited in traditional PBM arrangements. One of the main drivers behind this movement is transparency.... Technology is also a major factor."

GLP-1s Are Accelerating Spending Growth on Traditional Drugs

"Spending growth for traditional drugs -- simple-to-administer medications used to treat common health problems -- outstripped spending growth for specialty drugs -- pricey medications used to treat complex and chronic conditions -- for the first time in 2023 ... Coverage of GLP-1s for weight loss has steadily increased, though it's not universal.... 59% of health plans and 22% of employers report they cover GLP-1s for weight loss."

Ascension Cyberattack Exposes Data from 5.6 Million People

"Data from nearly 5.6 million people was exposed due to a ransomware attack on nonprofit health system Ascension this spring, according to a report to federal regulators. The attack compromised personal information from some current and former Ascension patients, senior living residents and employees ... The breach is the third largest reported to the HHS' Office for Civil Rights' healthcare data breach portal this year[.]"

AMA Sues MultiPlan, Insurers Alleging 'Cartel' to Fix Physician Prices

"Cost management company MultiPlan is facing yet another lawsuit for allegedly conspiring to underpay providers -- this time, from the largest physician association in the United States. The American Medical Association's complaint, filed Thursday in an Illinois district court, accuses MultiPlan of colluding with major health insurers to set artificially low reimbursement rates for out-of-network care, forcing providers to accept payments that often don't cover their operating costs." [American Medical Association v. MultiPlan, No. 24-10959 (N.D. Ill. complaint filed Oct. 24, 2024)]

CMS' First No Surprises Audit Targets Aetna, Finds Some Noncompliance

"The CMS’ first audit of an insurer for compliance with a law preventing surprise bills for consumers found some evidence to support provider allegations that insurers are gaming the system to lower or delay payments for out-of-network medical services."

Mental Health Benefits at Work: How We Can Go Further

"Modernizing our mental healthcare system will require action in three critical areas: [1] breaking down barriers to telehealth and virtual care; [2] significantly expanding the mental health workforce, in the short-and long-term; and [3] integrating mental health and physical healthcare."

Lawsuit Claims Humana Used Algorithm to Deny Care

"Humana is the latest insurer to be sued over its use of artificial intelligence in claims processing, with a lawsuit alleging the payer used AI model nH Predict to improperly deny care ... [P]laintiffs argued the payer prematurely cut payments for MA beneficiaries' rehabilitation care. According to the suit, Humana based the cuts on the AI model's 'rigid and unrealistic predictions for recovery' -- not doctors' recommendations -- despite knowing the model's estimations were often 'highly inaccurate.' " [Barrows v. Humana, Inc., No. 23-0654 (W.D. Ky. complaint filed Dec. 12, 2023)]

Cigna Hit with Second Class Action Suit Over Claims Automation Software

"Cigna is facing a second class action lawsuit over the health insurer's use of software to automate claims processing. The lawsuit ... alleges Cigna's 'procedure-to-diagnosis' or PxDx software reviewed and denied customer claims in batches without a medical professional reviewing those decisions. Cigna faces an almost identical lawsuit in California that was filed earlier this summer. The payer defends the technology as a standard review process similar to those used by other insurers." [Van Pelt v. Cigna, No. 23-1135 (D. Conn. complaint filed Aug. 25, 2023)]

Insured Adults Give Their Health Plans Positive Ratings, But Most Report Problems

"81% of insured adults rated their health plans' performance as 'excellent' or 'good.' ... Still, nearly 60% reported experiencing a problem with their coverage in the past 12 months, like their insurer paying less than expected or not being able to schedule an appointment with an in-network doctor. Nearly half who reported problems said it wasn't resolved or they weren't satisfied with the outcome."