Pharmacy Benefit Managers Under Fire: Regulatory Crackdowns, Legal Challenges, and Industry Shifts
Pharmacy Benefit Managers (PBMs) — the powerful intermediaries managing prescription drug benefits for insurers, employers, and government programs — are facing new levels of scrutiny from regulators, lawmakers, and industry stakeholders.
The IPO List is on the Chopping Block (Again) — What Providers Need to Know
This proposal reflects a broader shift toward more restrictive oversight of inpatient utilization. As CMS finalizes this policy, providers should be aware of the immediate compliance and reimbursement risks associated with the phase-out.
The Real Cost of Medicare Advantage: Fraud, Denials, and the Impact on Hospitals
Major Medicare Advantage (MA) insurers are facing increased scrutiny—not just from the federal government, but also in their relationships with hospitals and enrollees.
What’s Changing for ICHRA in the ‘One Big Beautiful Bill’
As a follow-up to our earlier post on the rise of ICHRAs, employers should be aware of significant changes incorporated in recently passed “One Big Beautiful Bill.”
Reinforcing the NSA: Connecticut District Court Finds Private Cause of Action for Enforcing IDR Determination Rewards
A district court out of Connecticut recently held that the No Surprise Act (“NSA”) creates a private cause of action that allows a prevailing party to enforce an Independent Dispute Resolution (“IDR”) award.
Consumers and Providers May Be Negatively Impacted by Nonprofit Agricultural Organization Medical Benefit Plans.
On April 3, 2025, Florida Senate passed bill SB480. The bill, if enacted into law, will authorize nonprofit agricultural organizations to provide “medical benefit plans” to their members.
The Rise of ICHRAs: A New Era in Employer Health Benefits
Individual Coverage Health Reimbursement Arrangements (ICHRAs) are a relatively new approach to employer-sponsored health coverage.
Navigating Hurdles in the Federal Independent Dispute Resolution (IDR) Process: How Insurers are Undermining Transparency of the IDR Process
The Federal Independent Dispute Resolution (IDR) process, established under the No Surprises Act (NSA), was designed to resolve out-of-network payment disputes between providers and insurers.
Another Challenge to the Affordable Care Act? The Supreme Court Gears Up to Hear Arguments on the Constitutionality of the Preventative Services Provision
The Supreme Court of the United States will hear arguments this spring from a case that threatens to rollback insurance coverage on preventative care.
Governing AI Use in Healthcare Claims Administration
Calculators, or “adding machines” as they were once called, once represented revolutionary technology.
