Health Plans & Networks
Expert articles and analysis related to health plans & networks.
AI Summary — Last 30 Days
Health plan scrutiny is intensifying around Medicare Advantage utilization management, with HHS OIG findings that the largest MA insurers denied prior authorization for long-term acute care and inpatient rehab at elevated rates—fueling provider and specialty-society pressure for MA reform and making post-acute access a central VBC contracting and network adequacy risk (OIG/MA prior authorization analysis). At the same time, payers and provider networks are moving deeper into condition-specific risk alignment, as Blue Cross NC’s Advanced Kidney Care program shows how specialty VBC models for CKD/ESRD can tie nephrology, care management, and total-cost accountability into payer strategy (Blue Cross NC AKC case study). The strategic through-line for ACOs and health systems is that plan partnerships are becoming more polarized: high-value networks with embedded data-driven care management can win preferred risk arrangements, while MA prior-auth friction and expensive therapies such as GLP-1s are raising the stakes for evidence, outcomes measurement, and contractually protected access pathways.
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