Emergency Medicine Revenue at Risk: Navigating the Algorithmic Squeeze
Emergency medicine groups are confronting a new wave of payer pressure driven by automated, opaque algorithms that downcode claims based on final diagnoses. Recent coding guideline changes in 2023 shifted billing emphasis to medical‑decision‑making, inflating acuity levels and prompting payers such as Aetna, UnitedHealthcare and Highmark to deploy aggressive diagnosis‑based downcoding, often using the Mercer LANE list. The resulting black‑box reviews can delay payments up to 45 days, generate zero‑pay determinations, and increase administrative costs. Providers must adopt data‑driven documentation, coder training, and proactive payer auditing to protect revenue.
Mayo Clinic CEO to Step Down at Year’s End
Mayo Clinic announced that CEO Dr. Gianrico Farrugia will step down at the end of 2026 after an eight‑year tenure. The board will likely select a new president and CEO in November, with the successor assuming the role on Jan. 1, 2027....
Worker Strikes Cost Kaiser over $1B in Q1
Kaiser Permanente disclosed that labor strikes in early 2026 added more than $1 billion to its first‑quarter expenses, pushing total costs up nearly 10% year‑over‑year to $33.9 billion. Operating income shrank 24% to $711 million, driving the operating margin down to 2.1% from...
Feds Propose Rule to Help Employers Expand Fertility Benefit Coverage
The Trump administration has issued a proposed rule that would let employers treat fertility benefits—such as IVF, medication and diagnostic services—as “limited excepted” benefits, similar to dental and vision coverage. The rule sets a $120,000 lifetime cap, indexed for inflation...
Federation of American Hospitals Taps New Government Relations Head
The Federation of American Hospitals (FAH) appointed Elizabeth Schwartz, former Merck executive director of U.S. policy and government relations, as senior vice president and head of government relations. Schwartz will lead advocacy for roughly 1,000 for‑profit hospitals as the sector...
Amwell Expects Smaller Losses in 2026 After Q1 Performance
Amwell lifted its 2026 adjusted earnings outlook after a first‑quarter beat, now forecasting a loss of $12 million to $16 million versus the prior $18 million to $24 million range. The company posted a Q1 net loss of $10.3 million on revenue of $54.9 million, an...
UPMC Reaches Deal with CommonSpirit to Acquire Ohio Health System
UPMC announced a definitive agreement to purchase Trinity Health System, a four‑hospital network with a broad outpatient footprint in Ohio’s Valley. The acquisition gives the Pittsburgh‑based health system its first foothold in Ohio, expanding its mid‑Atlantic presence into the Midwest....
Healthcare Bankruptcies Rise in Q1: Report
Healthcare Chapter 11 filings rebounded in Q1 2026, with twelve providers filing— a 33% increase from Q4 2025. Senior‑care firms and physician practices each contributed four cases, while mid‑market companies accounted for roughly two‑thirds of the total. The rise follows a dip in...
The AI Knowledge Gap We Can’t Afford to Ignore
Healthcare is rapidly integrating artificial intelligence, with two‑thirds of physicians using AI tools in 2024—a 78% surge from previous years. While AI can streamline chart review and surface clinical trends, experts warn that overreliance creates automation bias, magnifying documentation flaws...
Preparing for the 2026 HIPAA Changes: A Practical Guide for Healthcare Leaders
The Department of Health and Human Services will finalize a major overhaul of the HIPAA Security Rule in 2026, turning many previously optional safeguards into mandatory requirements. Organizations will face a tight compliance window—potentially as short as 60 days—once the...
What’s Next for Post-Acute Care: Data, Collaboration and the Path Forward
Post‑acute care is moving from a peripheral concern to a core pillar of health‑plan strategy. Plans are replacing delayed claims with real‑time clinical data, fostering tighter collaboration across hospitals and post‑acute providers, and embracing value‑based payment models that tie reimbursement...
Cost Management, Outpatient Unit Helped Tenet Weather Volume Headwinds in Q1
Tenet Healthcare posted $702 million profit on $5.4 billion revenue in Q1, beating Wall Street forecasts despite a 90‑basis‑point drop in acute‑care volumes and a 0.3% dip in outpatient admissions. The operator’s cost‑management program and a strong performance from its ambulatory surgical...
Consumer Health Data’s Regulatory Patchwork Is Growing. Relief Isn’t Coming.
The U.S. health‑data privacy regime is fracturing as HIPAA enforcement wanes and states race to fill the gap with their own laws. Consumer‑facing apps, wearables and AI tools are collecting sensitive information that falls outside traditional covered‑entity rules, creating a...
Health Disparities Persist Across States and May Widen Further with Federal Cuts: Report
A Commonwealth Fund report finds racial and ethnic health disparities persist across all 50 states despite modest gains in coverage after the pandemic. Native, Hispanic and Black populations face worse access and affordability than whites, and outcomes such as mortality...
UHS Reaffirms 2026 Volume Targets, Despite Seasonal Hits in Q1
Universal Health Services (UHS) said its first‑quarter admissions slipped due to a milder respiratory season and winter storms, with acute‑care volumes down 200 basis points and behavioral‑health volumes down 40‑50 basis points. Despite the dip, the for‑profit hospital chain reaffirmed...
Centene Hikes 2026 Profit Guidance After Buoyant Q1
Centene posted Q1 adjusted earnings of $3.37 per share, far surpassing analysts’ $2.25‑$2.30 expectations, driven by rate hikes that offset a 2‑million drop in ACA enrollment. Net profit rose 18% to $1.5 billion on revenue of $49.9 billion, prompting the company to...
Frequency of Medical Liability Lawsuits Is Declining, but Risk Remains for Doctors: AMA
The American Medical Association’s latest Physician Practice Benchmark Survey shows that the proportion of doctors sued at least once dropped to 28.7% in 2024 from 31.2% in 2022, indicating a modest decline in medical‑liability lawsuits. However, litigation risk remains concentrated...
ACA Subsidy Lapse Cost HCA Healthcare $150M in Q1
HCA Healthcare disclosed that the expiration of enhanced Affordable Care Act subsidies cost the company about $150 million in the first quarter, aligning with its forecast of a $600‑$900 million annual hit. ACA‑covered admissions fell roughly 15% year‑over‑year while admissions for uninsured...
As Coordination Grows More Complex, Intelligent Care Is Reshaping the Response
Intelligent care is emerging as a strategic framework that synchronizes people, processes, and technology across health systems. As patient flow becomes increasingly complex, many organizations still lack a unified, real‑time view of capacity, with only 17% reporting enterprise‑wide data visibility....
Why Health Plans Are Missing One of Their Most Costly Care Categories
Preference‑sensitive surgeries such as spine fusions, cataract procedures and hip replacements now represent roughly 30% of health‑plan medical spend and are growing 4‑6% annually. Up to 30% of these operations are medically inappropriate, costing commercial plans about $39 million and Medicare...
Medicare AI Prior Authorization Pilot Delaying Care in Washington: Report
A Medicare pilot that uses artificial‑intelligence‑driven prior authorizations—known as the WISeR model—has stretched approval times in Washington from roughly two weeks to four‑to‑eight weeks. The delay, documented by the Washington State Hospital Association, is forcing providers to add staff and...
FTC, US Anesthesia Partners Reach Settlement in Texas Price Collusion Case
The Federal Trade Commission reached a confidential settlement with U.S. Anesthesia Partners (USAP), a private‑equity‑backed anesthesia provider, over allegations it consolidated the Texas market and raised prices. USAP denied wrongdoing but agreed to settle to avoid costly litigation, while the...
Molina Controls Costs in Q1 but Future Medicaid Spending in Doubt
Molina Health Care posted a $14 million Q1 profit, beating analyst forecasts, while its medical loss ratios improved to 92% in Medicaid and 89.9% in Medicare Advantage. The gains were offset by a 2% drop in overall membership, driven by stricter...
Prices Rose After No Surprises Arbitration for some Care: Analysis
New Brookings research shows that prices set through the No Surprises Act’s independent dispute resolution (IDR) arbitration are dramatically higher than pre‑law in‑network rates. In 2024, imaging costs after arbitration were 767% above Medicare benchmarks, far exceeding the roughly 200%...
Moderna, After Losing US Funding, Rebounds to Start mRNA Bird Flu Vaccine Trial
Moderna has launched a Phase 3 trial of its mRNA‑1018 bird‑flu vaccine, enrolling about 4,000 healthy adults in the United States and the United Kingdom. The study follows the loss of a $766 million U.S. government contract, which had funded earlier development...
Blue Shield of California Taps Chief Pharmacy Officer
Blue Shield of California has appointed Hayley Park as senior vice president and chief pharmacy officer. Park, formerly vice president of pharmacy operations at Kaiser Permanente Northern California, will oversee the insurer’s prescription‑drug programs and the Pharmacy Care Reimagined initiative....
QuikTrip to Sell Urgent Care Clinics After 6 Years in Business
QuikTrip announced the sale of its MedWise urgent‑care network to Saint Francis Health System, transferring nine Oklahoma clinics. The retailer said proceeds will be used for employee retention bonuses, while its internal QuikMed primary‑care network remains intact. MedWise, launched in 2020...
Times Up: Hospitals and the 340B Markup Program Need Reforms
The 340B drug discount program, originally designed to help low‑income patients, now lets tax‑exempt hospitals buy medicines for pennies and resell them at full price. Hospitals and their for‑profit partners have turned the program into a $65 billion revenue stream, with...
3 Questions Every Payer Should Ask About Medical AI
Recent research shows 85% of healthcare leaders expect AI to reshape clinical decision‑making within five years, yet fewer than half of payers have a formal AI strategy. Compliance concerns—particularly around transparency, bias mitigation, and physician oversight—are driving tighter regulatory expectations...
3 Ways AI Is Humanizing Patient Care
A 2024 AMIA survey found that over 74% of clinicians say documentation tasks impede patient care, prompting hospitals to turn to AI solutions. Microsoft’s Dragon Copilot is being deployed at Cooper University Health Care, Mercy’s Fort Smith hospital, and the University...
CMS Proposes Repeal of Add-On Payment Path for Breakthrough Devices
The Centers for Medicare & Medicaid Services (CMS) has proposed repealing the alternative pathway for new‑technology add‑on payments (NTAP) beginning in fiscal year 2028, restoring the requirement that all devices demonstrate a substantial clinical improvement. The alternative pathway, created in...
Stakeholders Urge Labor Department to Finalize PBM Transparency Rule
Employers, lawmakers and patient groups urged the Labor Department to finalize a rule that forces pharmacy benefit managers (PBMs) to disclose detailed compensation data, including rebates and spread‑pricing. The DOL’s proposal, released in January, would require PBMs to share dollar‑level...
ACA Exchanges Will Continue to Shrink as Fewer Enrollees Pay Premiums, Analysis Suggests
The Wakely Consulting Group analysis warns that ACA exchanges could contract by 17% to 26% in 2026 as a wave of enrollees refuse to pay premiums after the expiration of COVID‑era enhanced tax credits. In January, 14% of beneficiaries failed...
More Insurance Claims Denials Are Being Overturned upon Appeal, Study Finds
A new JAMA study of roughly 51,000 New York claims shows denial overturn rates climbing from 38% in 2019 to nearly 53% in 2025. Overturn percentages differ sharply by service type—more than 78% for home‑health claims and just over 50% for...
With Health Costs Ballooning, Workers Turn to Wellness and the Internet, ADP Finds
ADP’s latest employee benefits survey shows soaring health‑care costs are prompting workers to delay or forgo treatment. Twenty‑six percent skipped needed care and 22% cut medication use, both up from 2020 levels. To cope, 68% of employees now seek medical...
Tenet CIO to Retire at Year End
Tenet Healthcare announced that Chief Information Officer Paola Arbour will retire on Dec. 31, 2026, but will remain on a part‑time basis through early 2028 to aid the transition. Arbour, who has led Tenet’s IT strategy, operations and finances since 2018,...
CMS Accepts More than 150 Providers, Digital Health Firms for ACCESS Model
The Centers for Medicare & Medicaid Services (CMS) has granted provisional approval to more than 150 providers and digital‑health firms for its Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model. The 10‑year experiment, launching in July, will pay participants...
CMS Proposes New Deadlines for Prior Authorizations for Drugs
The Centers for Medicare & Medicaid Services (CMS) has proposed a rule that would impose firm deadlines on federally regulated insurers for electronic prior authorizations (PA) of prescription drugs. Medicaid and CHIP plans would have 24 hours to respond, while ACA...
Fix Operations, Not Contracts: How to Make Value-Based Care Work
Value‑based care (VBC) is stalling because providers focus on payment incentives rather than the operational changes needed to deliver coordinated, outcome‑driven care. A 2025 provider survey shows two‑thirds view analytics as essential, yet over half cite data quality and interoperability...
From Afterthought to Advantage: How Health Plans Are Rethinking Post-Acute Care
Health insurers are moving post‑acute care from a reactive afterthought to a proactive advantage. Real‑time clinical visibility and AI‑driven risk models now let care teams intervene while members are still in transition, rather than waiting for claims data. Integrated workflows...
From Vision to Reality: How Ambulatory Practices Actually Become Automated
Automation in ambulatory care is shifting from a buzzword to a daily reality, but success hinges on more than software. Practices that first map and standardize workflows—intake, eligibility, prior authorizations—create a solid foundation for automation tools. Engaging frontline staff early...
Hospital M&A Rebounds After 2025 Lull
Hospital and health‑system M&A rebounded in Q1 2026, with 22 announced deals—the highest first‑quarter total in six years. The quarter’s transacted revenue hit $14.5 billion, buoyed by several mega‑mergers exceeding $1 billion in annual revenue. Divestitures dominated, accounting for 15 of the...
Most Health AI Users Don’t Rate Chatbots as Highly Accurate: Poll
A recent Pew poll of over 5,000 U.S. adults shows that while more than 20% occasionally use AI chatbots for health questions, only 18% consider the information very or extremely accurate. By contrast, 65% trust their providers for accurate advice,...
Orlando Health Agrees to Acquire Alabama-Based RMC Health System
Orlando Health announced an agreement to acquire Anniston‑based RMC Health, adding a 375‑bed hospital and outpatient network to its Alabama region. The transaction, which awaits regulatory clearance, is slated to close in the fall of 2026. This follows Orlando Health’s...
ICHRAs, a Growth Opportunity for Insurers, Face Uphill Battle
Individual Coverage Health Reimbursement Arrangements (ICHRAs) are gaining traction as insurers search for growth amid stagnant commercial plan enrollment. Adoption jumped 19% from 2024 to 2025, with a 34% surge among large employers, prompting payers like Centene and Oscar to...
Digital Health Funding Concentrates in Fewer Startups: Report
Digital health startups secured $4 billion in the first quarter of 2026, up $1 billion from a year earlier, but the capital was funneled into fewer deals. Only 110 transactions occurred, down from 122, while a dozen mega‑deals of $100 million or more...
Jefferson Health Sues Aetna over Medicare Advantage ‘Downcoding’ Policy
Jefferson Health and Lehigh Valley Physician Hospital Organization have filed a federal lawsuit against Aetna, alleging that the insurer’s new “downcoding” policy unlawfully reduces Medicare Advantage inpatient payments. The policy classifies 1‑4 night admissions as low‑severity and reimburses them at...
Veradigm Names CFO as It Works to Get Current on Financial Filings
Veradigm announced Christian Greyenbuhl will become its chief financial officer, effective May 11 or the day after the company files its overdue 2023 and 2024 annual reports. The health‑IT firm was delisted from Nasdaq in early 2024 after missing quarterly and annual...
Insurers Committed to Cutting Prior Authorizations Have Eliminated 11% so Far
Major insurers have trimmed 11% of prior authorizations, eliminating roughly 6.5 million requests for U.S. patients, according to AHIP and the Blue Cross Blue Shield Association. The reduction is most pronounced in Medicare Advantage, where cuts exceed 15%. Insurers also report...
Standing up to Rising Prescription Drug Costs Increases Access to Breakthrough Medications
CVS Caremark negotiated a price reduction for Yeztugo, a long‑acting injectable PrEP drug with an original list price of $28,000 per year, to improve affordability and access. The medication offers twice‑yearly dosing, which can dramatically boost adherence compared with daily...