Health Plan Operations
Expert articles and analysis related to health plan operations.
AI Summary — Last 7 Days
Federal oversight of health plan operations intensified this week, with HHS OIG finding that the largest Medicare Advantage organizations—UnitedHealth, Humana, and CVS/Aetna—denied prior authorization for long-term acute care and inpatient rehab at unusually high rates, while separate reporting noted many SNF denials were later overturned—fueling provider concerns that MA utilization management is constraining post-acute access and shifting administrative burden onto VBC networks (OIG findings). At the same time, the Trump administration’s CMS paused new Medicare enrollment for hospice and home health providers for six months, adding capacity and network-adequacy pressure in care-at-home models, while Medicaid managed care scrutiny expanded around maternal health “ghost networks” and health systems continued dropping MA contracts over payment friction and denials (CMS enrollment freeze). For ACOs, MA risk-bearing groups, and payer strategists, the throughline is a tightening operational environment: access, prior auth, network accuracy, and AI-driven coding/documentation cost inflation are becoming central battlegrounds in value-based performance and regulatory risk.
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