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Elevance Health's Medicare Advantage plans face federal sanctions. The University of Mississippi Medical Center clinics reopen after a ransomware attack. And the FDA warns telehealth companies about marketing compounded weight loss drugs. That's coming up on today's episode of The Gist Healthcare Podcast. Hosted on Acast. See acast.com/privacy for more information.
In this week's episode of Medicine: The Truth, hosts Jeremy Corr and Dr. Robert Pearl unpack a wide range of developments shaping healthcare in America today, including the TrumpRx drug discount program. From new legislation affecting telehealth and pharmacy benefit managers (PBMs) to the rapid spread of measles and growing public concern about vaccine policy, this month's discussion highlights the policy decisions and scientific debates influencing medicine right now. The episode opens with the latest federal legislation passed to avert a government shutdown. While healthcare was not the central focus of this particular political battle, the bill contains several provisions that affect medical practice. These include extensions for telehealth coverage and hospital-at-home programs, reforms targeting PBM transparency and new requirements designed to address “ghost networks” in Medicare Advantage provider directories. Dr. Pearl explains that while these provisions represent incremental progress, they are unlikely to solve the larger problems driving healthcare costs and access challenges in the United States. Here are the other major storylines from episode 104: Healthcare costs remain nation's top concern: A new KFF poll finds that healthcare expenses rank above food, housing and utilities as the economic issue Americans worry about most. Prior authorization frustrations grow: Many patients report delays or denials of care due to insurance requirements, highlighting persistent tension between insurers, physicians and patients. Drug pricing debates continue: Pearl examines a new prescription drug website initiative and explains why it may have limited impact compared with broader policy proposals such as “most favored nation” pricing. Telehealth's uncertain future: Although the latest legislation extends certain pandemic-era flexibilities, the lack of a permanent solution leaves virtual care programs in limbo. PBM reforms move forward slowly: New policies aim to increase transparency and reduce incentives tied to drug list prices, though Pearl notes that meaningful change will depend on future implementation. Site-neutral payment gains attention: A provision requiring unique identifiers for outpatient services could pave the way for policies that eliminate higher reimbursement for hospital-owned facilities providing identical care. Measles outbreaks surge: Nearly a thousand cases have already been reported in 2026, with the overwhelming majority occurring among unvaccinated children. Trust in the CDC declines: Polling shows confidence in the agency has dropped significantly following changes to vaccine recommendations. Independent vaccine review groups emerge: Medical organizations and states are forming new committees to evaluate vaccine evidence as federal guidance becomes more contested. Early colon cancer deaths rise: The death of actor James Van Der Beek at age 48 highlights the growing incidence of colorectal cancer among younger adults and the importance of earlier screening. FDA confusion over a new flu vaccine: The agency initially declined to review Moderna's mRNA-based flu vaccine before reversing course and agreeing to evaluate it ahead of the next flu season. Younger Americans face worsening health trends: New claims data suggest chronic disease is appearing earlier among millennials and Gen Z, driven by lifestyle factors and reduced connection to primary care. Wearable data reveal health disparities: Apple Watch data show significant differences in resting heart rates across states, reflecting variations in lifestyle, access to care and public health conditions. As the episode concludes, Dr. Pearl warns that growing political conflict around vaccines and biomedical research risks undermining public trust in science. The consequences, he argues, could shape American medicine for decades to come. Tune in for more fact-based analysis and discussion of the biggest stories in healthcare. * * * Dr. Robert Pearl is the author of the new book “ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine” about the impact of AI on the future of medicine. Fixing Healthcare is a co-production of Dr. Robert Pearl and Jeremy Corr. Subscribe to the show via Apple, Spotify or wherever you find podcasts. Join the conversation or suggest a guest by following the show on Twitter and LinkedIn The post MTT #104: TrumpRx, rising measles cases & the politics of vaccine science appeared first on Fixing Healthcare.
This morning, Don breaks down the latest updates on the rapidly expanding crisis in the Middle East. As U.S. and Israeli strikes against Iran continue, regional retaliation spreads, and world powers grapple with what may be a long, costly conflict with no clear end in sight. We'll talk about how this is already affecting American lives, from rising fuel prices at the pump to economic ripple effects and global instability, and what might come next as tensions escalate day by day. Then, we'll shift gears to take a look at today's major political news from Texas: James Talarico has won the Democratic primary for the U.S. Senate race, emerging victorious over Congresswoman Jasmine Crockett in a closely watched contest that could reshape statewide politics this November. Can he flip a long-Republican seat in the general election? We'll break down what this win means and what lies ahead. This episode is brought to you by Incogni. Go to https://incogni.com/donlemon and use code donlemon for 60% off. Incogni HELPS wipe yourself from the Internet — they can't harm you if they can't find you. Click the link below to claim your 60% off and get your personal data off the market! Erase yourself from the internet. This episode is sponsored by 120Life. Go to https://incogni.com/donlemon and use code donlemon for 60% off. Incogni HELPS wipe yourself from the Internet — they can't harm you if they can't find you. Click the link below to claim your 60% off and get your personal data off the market! Erase yourself from the internet This episode is sponsored by BetterHelp. BetterHelp makes it easy to get matched online with a qualified therapist. Sign up and get 10% off at https://BetterHelp.com/donlemon This episode is brought to you by Shopify. See less carts go abandoned and more sales go with Shopify and their Shop Pay button.Sign up for your one-dollar-per-month trial today at https://SHOPIFY.COM/lemon For free and unbiased Medicare help, dial 212-931-0855 to speak with my trusted partner, Chapter, or go to https://askchapter.org/don DISCLAIMER: Chapter and its affiliates are not connected with or endorsed by any government entity or the federal Medicare program. Chapter Advisory, LLC represents Medicare Advantage HMO, PPO, and PFFS organizations and stand alone prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal. While we have a database of every Medicare plan nationwide and can help you to search among all plans, we have contracts with many but not all plans. As a result, we do not offer every plan available in your area. Currently we represent 50 organizations which offer 18,160 products nationwide. We search and recommend all plans, even those we don't directly offer. You can contact a licensed Chapter agent to find out the number of products available in your specific area. Please contact Medicare.gov, 1-800-Medicare, or your local State Health Insurance Program (SHIP) to get information on all of your options. Average potential savings are based on realized premium, co-pay, and out of pocket savings estimates self-reported by consumers that worked with Chapter Advisory LLC to enroll in a Medicare Supplement, Medicare Advantage, and/or Part D Prescription Drug Plan. The average is limited to consumers that chose to self-report. Savings information is subject to periodic updates and corrections. There is no guarantee of savings and any savings may vary by policy type, state, or other factors. Learn more about your ad choices. Visit megaphone.fm/adchoices
Today, Don breaks down Day 2 of Kristi Noem's testimony, this time before the House, and let's just say… it was wild. From tense exchanges to repeated dodges, lawmakers pressed Noem hard on her leadership, policy decisions and accountability. Instead of clear answers, viewers saw deflection, contradiction, and mounting frustration from members of Congress on both sides of the aisle. What stood out? What questions did she refuse to answer? And after two days of heated hearings, will there be any real consequences, or is this just another Washington spectacle with no follow-through? This episode is brought to you by Incogni. Go to https://incogni.com/donlemon and use code donlemon for 60% off. Incogni HELPS wipe yourself from the Internet — they can't harm you if they can't find you. Click the link below to claim your 60% off and get your personal data off the market! Erase yourself from the internet. This episode is sponsored by 120Life. Go to https://incogni.com/donlemon and use code donlemon for 60% off. Incogni HELPS wipe yourself from the Internet — they can't harm you if they can't find you. Click the link below to claim your 60% off and get your personal data off the market! Erase yourself from the internet This episode is sponsored by BetterHelp. BetterHelp makes it easy to get matched online with a qualified therapist. Sign up and get 10% off at https://BetterHelp.com/donlemon This episode is brought to you by Shopify. See less carts go abandoned and more sales go with Shopify and their Shop Pay button.Sign up for your one-dollar-per-month trial today at https://SHOPIFY.COM/lemon For free and unbiased Medicare help, dial 212-931-0855 to speak with my trusted partner, Chapter, or go to https://askchapter.org/don DISCLAIMER: Chapter and its affiliates are not connected with or endorsed by any government entity or the federal Medicare program. Chapter Advisory, LLC represents Medicare Advantage HMO, PPO, and PFFS organizations and stand alone prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal. While we have a database of every Medicare plan nationwide and can help you to search among all plans, we have contracts with many but not all plans. As a result, we do not offer every plan available in your area. Currently we represent 50 organizations which offer 18,160 products nationwide. We search and recommend all plans, even those we don't directly offer. You can contact a licensed Chapter agent to find out the number of products available in your specific area. Please contact Medicare.gov, 1-800-Medicare, or your local State Health Insurance Program (SHIP) to get information on all of your options. Average potential savings are based on realized premium, co-pay, and out of pocket savings estimates self-reported by consumers that worked with Chapter Advisory LLC to enroll in a Medicare Supplement, Medicare Advantage, and/or Part D Prescription Drug Plan. The average is limited to consumers that chose to self-report. Savings information is subject to periodic updates and corrections. There is no guarantee of savings and any savings may vary by policy type, state, or other factors. Learn more about your ad choices. Visit megaphone.fm/adchoices
If you'd like to work with us on your Medicare health plan, we're licensed in 45 states and actively helping clients across the country. Christian and the team at Everything Senior Insurance represent many of the top insurance companies in the Medicare space. We're happy to help—just reach out! ➡️ Visit our site: https://www.eseniorinsurance.com✅ Call us: (801) 255-5340
In this episode, Karen Walker Johnson, Chief Executive Officer of Clever Care Health Plan, discusses how culturally competent, value based care is reshaping Medicare Advantage. She shares insights on strengthening provider trust, investing in community based engagement, and advocating for quality metrics that recognize cultural competence to improve outcomes and affordability.
In this episode, Jennifer L. Kowalski, Vice President of the Public Policy Institute at Elevance Health, discusses how rigorous research and data shape Medicare Advantage strategy, from supplemental benefits to dual eligible integration. She shares insights on affordability, care navigation, and how evidence based policy can strengthen value, access, and long term sustainability in the program.
In this episode, Karen Walker Johnson, Chief Executive Officer of Clever Care Health Plan, discusses how culturally competent, value based care is reshaping Medicare Advantage. She shares insights on strengthening provider trust, investing in community based engagement, and advocating for quality metrics that recognize cultural competence to improve outcomes and affordability.
IANR 2608 022126 Line Up 4-6pm INTERVIEWS (Guest host Gautam Sinha in for Pramod)Here's the guest line-up for Sat, Feb 21, 2026 from 4 to 6pm CST on Indo American News Radio (www.IndoAmerican-news.com), a production of Indo American News. We areon 98.7 FM and you can also listen on the masalaradio app.By Monday, hear the recorded show on Podcast uploaded on Spotify, Apple Podcasts, Pocket Casts, Radio Public and Breaker or go to our website and click on the IANR link. Our Podcast has been rated #2 among 100 Podcasts in Houston by feedspot.com. We have 6 years of Podcasts and have had thousands of hits.TO SUPPORT THE SHOW, SELECT FOLLOW ON OUR FREE PODCAST CHANNEL AND YOU'LL BE NOTIFIED OF NEWUPDATES.4:20 pm Although Rishi Bhutada was born and raised in Houston, he has been rooted in Indian culture and his Hindu heritage. He is an active member of the Hindu American Foundation which has advocated to correct items that depict Hindus in a terrible light. The State Board of Education has passed the Bluebonnet Learning lessons rule to teach Biblical studies in K through 5 classrooms across the state. He joins us to explain why Hindus should oppose this and also talk about the annual HAF gala to be held on Saturday, April 11.4:50 pm We are out of the Annual Open Enrollment period to sign up for Medicare policies but there are still extenuating circumstances that may allow you to sign up for Medicare Advantage plans. We are joined once again by Medicare Insurance Broker Kaushi Shah who will explain what those circumstances can be and how to go about enrolling now, what the costs may be and why it is so important for us to pay attention before signing up.5:20 pm Many of us have never even heard of the field of Epigenetics which deals with the study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself. Sheetal Kohli, a teacher at Harmony Public Schools, has devoted herself to strengthening STEM education across Houston and encouraging inquiry-based learning. We turn to her to explain how Epigenetics can influence health and disease of an individual.Also stay tuned in for news roundup, views, sports and movie reviews.TO BE FEATURED ON THE SHOW, OR TO ADVERTISE, PLEASE CONTACT US AT 713-789-NEWS or 6397 or at indoamericannews@yahoo.comPlease pick up the print edition of Indo American News which is available all across town at grocery stores. Also visit our website indoamerican-news.com which gets 90,000+ hits to track all current stories.And remember to visit our digital archives from over 18 years. Plus, our entire 45 years of hard copy archives are available in the Fondren Library at Rice University.
MedPod Today: the podcast series where MedPage Today reporters share deeper insight into the week's biggest healthcare stories. This week, MedPage Today reporters discuss the revolving door leadership at NIH's Institutes and Centers, UnitedHealthcare's controversial new Medicare Advantage policy, and a bill that would erase two decades worth of certain types of state nursing board discipline. Episode produced and hosted by Rachael Robertson. Sound engineering by
In this episode, Jakob Emerson, Associate News Director at Becker's Healthcare, breaks down limited federal direction following the State of the Union, a potential drop in ACA exchange enrollment, Medicare Advantage surpassing 55 percent penetration, and how insurers and health systems are navigating a rapidly changing and increasingly strained payer landscape.
We're marking Rare Disease Month 2026 by highlighting the powerful story of Shanthi Hegde, a young patient advocate working to transform how bleeding disorders are understood, treated, and supported. This work is fueled by her own arduous journey with two rare bleeding disorders and immune dysregulatory syndrome, and an extended diagnostic odyssey marked by dismissal, underdiagnosis, and structural bias. “I was told many times by many providers that these disorders are not common in Indians and that my bruises were there just because I'm brown.” Admirably, Shanthi pushed past this mistreatment, advocated for her medical needs, and devoted herself to tackling a range of issues confronting rare disease patients from mental health access to affordable drug pricing to research equity. In this remarkable Year of the Zebra conversation with host Lindsey Smith, you'll also learn about: Shanti's work with the Hemophilia Federation of America; How gaps extend beyond treatment to include insurance coverage, provider training, and substance use care; What clinicians can do to improve the work they do with rare disease patients. Join us for a conversation that connects patient voice to system change, and explores what real equity for rare disease communities will require. Mentioned in this episode:Hemophilia Federation of AmericaShanthi's LinkedIn Profile If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our episodes at www.osmosis.org/podcast
If you'd like to work with us on your Medicare health plan, we're licensed in 45 states and actively helping clients across the country. Christian and the team at Everything Senior Insurance represent many of the top insurance companies in the Medicare space. We're happy to help—just reach out! ➡️ Visit our site: https://www.eseniorinsurance.com✅ Call us: (801) 255-5340
This year has been something of a reckoning for Medicare Advantage. Senator Grassley's scathing report of UHG's risk adjustment practices, and the Kaiser $556 million settlement to resolve False Claims Act allegations of upcoding, opened eyes, and got many in the industry talking. I wanted to get someone on the show with opinions, unafraid to speak their mind and share their perspective. I've found that person. Betty Stump is Senior Solution Consultant for Edifecs, a Cotiviti Business. She is in the business of risk adjustment and value-based care on the vendor side, but is never afraid to offer her opinion on the industry, pro and con. And with more than 20 years in the industry across multiple well-known companies, it's an informed one. Listen in as we discuss: What is working in value-based care/risk adjustment—and where have we gone wrong? Recent conference disillusionment. Kaiser DOJ fine and the Grassley report taking aim at UHG's aggressive risk adjustment strategy: Betty's thoughts and where does this heightened era of scrutiny put risk adjustment coders. Do we need to elevate the MEAT standard? What are organizations missing with risk adjustment? Great, practical, low-tech suggestions for RAF capture including using your 2025 end-of-year roster to identify those patients with high-risk conditions and engage in proactive outreach to get patients seen. V28 of CMS-HCCs with V24 in the rear-view mirror. Truthful tech talk: How leaders can get a seat at the table, how to get a vendor's ear to modify functionality, and truth and hype in CDI tech How should a CDI or coder interact with a machine prompt from a suspecting tool? Looking back at a colorful 20-year career in the consulting life, and a thoughtful selection for the Off the Record Spotify playlist by a fellow music enthusiast.
In 1997, Bill Clinton and Newt Gingrich shocked Washington by coming together to pass the Balanced Budget Act — a bipartisan deal that led to the first federal budget surplus in nearly 30 years.But what did it really change?This episode breaks down how the BBA cut $112 billion from Medicare, reshaped Medicaid, created Medicare+Choice (now Medicare Advantage), introduced the Sustainable Growth Rate (SGR), and paired healthcare cuts with $95 billion in tax breaks.Was it fiscal responsibility… or the beginning of a long-term shift toward privatization?We're diving into the 1995 government shutdown, the “Third Way,” rural hospital impacts, the Doc Fix crisis, and what critics like Bernie Sanders warned about on the House floor.www.stayskeptical.comWise Wolf Gold: https://www.wolfpack.gold/?ref=jvujkwgsSources: https://docs.google.com/document/d/1jcwvgWpPz8GqLxNwpeJM7AHqBJL2O3JWVdE8ggKK7_8/edit?usp=sharingwww.stayskeptical.comWise Wolf Gold: https://www.wolfpack.gold/?ref=jvujkwgsSources: https://docs.google.com/document/d/1jcwvgWpPz8GqLxNwpeJM7AHqBJL2O3JWVdE8ggKK7_8/edit?usp=sharing
Prior authorizations among Medicare Advantage plans have drawn criticism and concern from patients, providers, lawmakers, and regulators. But hospitals and doctors are uniquely positioned to advocate for their patients' access to and coverage for care. What's necessary is the need to understand the rules of the process. And Medicare Advantage plans have many of them.During the next live edition of the venerable Monitor Monday, the Internet broadcast, Richelle Marting, a healthcare attorney, and certified coder, will help you understand when and how Medicare Advantage plans can use prior authorizations for the critical protections you need to know to advocate for patient care.Broadcast segments will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legislative Update: Matthew Albright of Zelis, will report on current healthcare legislation.
The Food and Drug Administration will review Moderna's new flu vaccine after reversing course. Medicare Advantage growth in 2026 is trailing prior years. And Amazon is expanding same-day prescription delivery to nearly 5,000 cities nationwide. Those stories and more on today's episode of The Gist Healthcare Podcast. Hosted on Acast. See acast.com/privacy for more information.
Leading a major health system today means juggling patient-first ethics with a financing model that keeps tightening the screws. In this episode, Chris Van Gorder, President and Chief Executive Officer of Scripps Health, explains why health care is becoming structurally unaffordable amid soaring premiums, uncompensated emergency care, and rising input costs. He describes how hospitals have become the default safety net as county systems disappear, while underpayment by Medicare and Medicaid forces cost shifting onto employers and commercially insured patients. Van Gorder also highlights California's seismic rebuilding mandates, which create massive capital pressure without matching reimbursement. He critiques managed care, value-based care, and Medicare Advantage for pushing risk onto providers through prior authorization and denials, recounting Scripps' difficult decision to exit several Medicare Advantage contracts after heavy losses and the downstream impact on patients. Tune in and learn how payment design, intermediaries, and regulation shape what hospitals can sustain and what patients can access. Resources: Connect with and follow Chris Van Gorder on LinkedIn. Follow Scripps Health on LinkedIn and explore their website! Learn more about your ad choices. Visit megaphone.fm/adchoices
MEDICARE ADVANTAGE MINUTE! ONE THIRD OF INSURED ADULTS SAY THAT PRIOR AUTHORIZATION HAS BEEN A MAJOR BURDEN IN ACCESSING CARE! We address correspondence from some who have unusual situations with respect to Medicare. An 81-year-old man is covered by Original Medicare only. His son writes to ask about the possibilities of improving his father's protection by acquiring a Medicare supplement. Then Len writes to ask whether the series of steps his friend Dan has planned makes sense. The goal: disenroll from Dan's existing Medicare Advantage plan and begin to enjoy superior Medicare protection and freedom of choice with a supplement plan, Finally, play along with a quiz related to the most and least friendly cities for those seeking STEM jobs. Contact me at: DBJ@MLMMailbag.com (Most severe critic: A+) Visit us on: BabyBoomer.ORG Inspired by: "MEDICARE FOR THE LAZY MAN 2026; SIMPLEST & EASIEST GUIDE EVER!" "MEDICARE ENROLLMENT GUIDE!" (Free download from site below) "MEDICARE DRUG PLANS: A SIMPLE D-I-Y GUIDE" For sale on Amazon.com. After enjoying the books, please consider returning to leave a short customer review to help future readers. Official website: https://www.MedicareForTheLazyMan.com.
AM Best and industry experts share their 2026 outlook on the Medicare Advantage business segment, including the key drivers. (Event Date: January 15, 2026)
Living in a rural area? A limited provider network can quickly become a major healthcare headache. In this episode, we explain why Medicare Supplement plans often outperform Medicare Advantage for rural residents, offering broader doctor access, fewer restrictions, better flexibility for travel, and more peace of mind when care options are limited.
Worried about Medicare Advantage claim denials? In this episode, we break down why services get denied, how prior authorization and medical necessity rules work, and what these restrictions can mean for your access to care. Learn why a Medicare Supplement plan may offer a safer, more predictable option for protecting your health and peace of mind.
What happens if you have a medical emergency while on Medicare? In this episode, we compare how Medicare Supplement and Medicare Advantage plans handle emergencies, covering key differences in costs, provider networks, and travel coverage. Learn which option may offer stronger protection for both your health and your finances when the unexpected happens.
The Non-Market Reality of Healthcare Carrier Marketplaces with Dr. Jacob Asher. In this episode of Relentlessly Seeking Value, host Stacey Richter introduces the 'No Market' series focused on the healthcare sector's lack of competitive market dynamics, which affects cost and quality. The episode features a conversation with Dr. Jacob Asher, who has extensive experience as a Chief Medical Officer at major healthcare plans. They discuss the stagnant nature of commercial carrier marketplaces, particularly in California, and the various factors contributing to this stasis, including employer inertia, the influence of employee benefit consultants, and the strategic focus of carriers on Medicare Advantage over commercial business. They also explore how carriers' dependence on existing provider networks and contractual negotiations based on member volumes contribute to a lack of meaningful competition. The episode highlights the challenges faced by plans attempting to innovate or differentiate on quality and the systemic issues that perpetuate the current equilibrium. === LINKS ===
Few issues have tested public trust in medicine as deeply as vaccines, and few individuals have influenced that dialogue more than Dr. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia and a longtime member of the FDA's Vaccine Advisory Committee. In this timely and candid interview with Raise the Line host Lindsey Smith, Dr. Offit points to this year's severe flu season and a resurgence of measles as alarming proof points of how a changing federal perspective on vaccine policy is having a real impact on public health. “You'd like to think you can educate about the importance of vaccines, but I fear at this point the viruses themselves are doing the educating.” In this wide ranging discussion, Dr. Offit also addresses: The rigorous and painstaking process of developing vaccines, based on his experience co-inventing the rotavirus vaccine. Shifting levels of public trust in scientific organizations. Promising innovations in vaccine development. Don't miss this deeply-informed perspective on the interplay of science, policy, and public education, and his encouraging message to young clinicians about managing the current challenges in public health. Mentioned in this episode: Vaccine Education Center at Children's Hospital of PhiladelphiaPerelman School of Medicine If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our episodes at www.osmosis.org/podcast
Legislation has played a defining role in how dialysis care is delivered in the United States, directly influencing access, coverage, and patient choice. In this episode of Kidney Commute: Pitstop, host Osama El Shamy, MD, FASN, FNKF, is joined by Lauren Drew, JD, and Eugene Lin, MD, MS, FASN for an in depth discussion on the policy decisions that have shaped kidney care. The conversation traces key legislative milestones, including the creation of the ESRD benefit, the Medicare dialysis bundle, Medicare Advantage expansion, and the Advancing American Kidney Health Initiative. Speakers also examine the current legislative landscape, its impact on dialysis patient choice, and opportunities for professional advocacy in kidney care.
Medicare Advantage organizations are facing a significant policy year as CMS releases updates that signal a recalibration of the Stars program and broader regulatory framework. Recent rule-making and guidance point to changes in measurement priorities, simplification efforts, and evolving expectations around quality performance and operational execution. While some updates appear administrative on the surface, they carry implications for how plans evaluate performance, align internal teams, and prepare for future contract years. The episode explores what these federal signals suggest about CMS's direction and how plans can interpret them within the context of long-term strategy. What do these changes truly mean for 2027 and beyond—and how should payers respond now? Listen to the full episode to uncover the deeper strategic signals shaping the future of Medicare Advantage.About Our Guest:Shelby Jansen has deep expertise in guiding payer quality strategies to meet CMS expectations, reflecting NCQA updates, optimizing Stars and HEDIS programs, and guiding health plans through digital transformation.
If you'd like to work with us on your Medicare health plan, we're licensed in 45 states and actively helping clients across the country. Christian and the team at Everything Senior Insurance represent many of the top insurance companies in the Medicare space. We're happy to help—just reach out! ➡️ Visit our site: https://www.eseniorinsurance.com✅ Call us: (801) 255-5340
Once a high growth, high margin line of business for health plans, Medicare Advantage (MA) is now in the middle of a financial reset. Growth has slowed, margins have turned negative, and federal financial support is eroding — with CMS proposing a near flat reimbursement increase for 2027. As a result, plans are exiting markets, tightening benefit designs, and shifting their focus toward Special Needs Plans (SNPs). At the same time, seniors are facing rising costs, fewer perks, and more frequent plan changes. To cut through the noise and understand what's really happening beneath the headlines, host Rachel (Rae) Woods speaks with Advisory Board experts Sally Kim and Aaron Hill about the new divide emerging in MA: between plans equipped to manage the intensive needs of high cost seniors and execute on SNP strategies — and those that will be forced to exit markets or rethink their MA ambitions entirely. Listen as they break down how MA's financial and clinical headwinds are reshaping payer–provider relationships — and why future success depends on disciplined focus, deeper provider partnerships, and new investments in technology and cross benefit management. We're here to help: Tool | Medicare Market Explorer Webinar | Medicare Advantage: Insights on today's more competitive market Webinar | Medicare Advantage: The latest on product design and growth Podcast | Ep. 227: The changing tide of Medicare Advantage Expert Insight | 3 data-driven insights on Medicare Advantage Star Ratings Ready-to-Use Slides | Medicare Advantage market outlook 2026 Advisory Board Summit Washington, D.C. A transcript of this episode as well as more information and resources can be found on RadioAdvisory.advisory.com.
If you're approaching age 65, Medicare can feel overwhelming fast. Between Parts A, B, C, and D and the timing rules tied to each—it's easy to make a costly mistake if you don't understand how the pieces fit together. In this episode, I walk through the Medicare "alphabet," explaining what each part does, when enrollment matters most, and how your decisions interact with the rest of your retirement plan. We also cover common questions that come up when clients transition from employer-sponsored coverage to Medicare for the first time. Whether retirement is right around the corner or still a few years away, this episode is designed to help you avoid penalties, coverage gaps, and surprises down the road. You will want to hear this episode if you are interested in... [00:00] Understanding Medicare Parts A, B, C, and D [01:00] When you can delay Medicare without penalties [02:30] How late enrollment penalties actually work [06:00] Timing Medicare enrollment to avoid coverage gaps [07:30] What Medicare does—and does not—cover [10:00] Medicare Advantage vs. supplemental coverage [14:00] How state rules can affect your long-term options Why Medicare Timing Matters Medicare isn't just about what coverage you choose it's also about when you enroll. Missing key enrollment windows can trigger penalties that last for life, even if the mistake was unintentional. In this episode, I explain the rules around initial enrollment, special enrollment periods, and why employer coverage plays such a critical role in determining your options. Choosing Between Medicare Advantage and Supplemental Coverage Once you enroll in Parts A and B, you still need to decide how to fill the gaps. Medicare Advantage plans and Medigap policies take very different approaches to coverage, costs, and flexibility. I outline how these options compare, what tradeoffs to be aware of, and why the "best" choice depends heavily on your health, preferences, and where you live. Building Medicare Into Your Retirement Plan Medicare decisions don't exist in a vacuum. Premiums, out-of-pocket costs, and coverage choices all affect cash flow in retirement. In this episode, I explain how to think about Medicare as part of a larger retirement strategy, not just a healthcare decision—so your plan stays aligned as you transition out of the workforce. Resources Mentioned RetireWithRyan.com Medicare.gov Connect With Ryan Subscribe to the Retire With Ryan YouTube Channel Download my entire book for FREE
In this Bright Spots in Healthcare episode, Medicare Advantage leaders confront a hard truth: high activity does not guarantee high impact. As Stars cut points rise and margins tighten, traditional segmentation and broad outreach strategies are no longer sufficient. This discussion explores how leading plans are shifting from static stratification to dynamic signal monitoring, identifying which members are realistically movable, and embedding behavioral intelligence directly into operational workflows. The focus is not on doing more. It is on doing what measurably drives lift. Our guests include: Amin Serehali, Chief Data and Analytics Officer, Independent Health Mike Leiper, Director of Government Quality Programs, Highmark Brendan Generelli, Director of Medicare Stars and Quality, Johns Hopkins Health Plans David Burianek, Chief Strategy Officer for Health Plans, MedOrion Together, they explore: How plans are distinguishing between theoretical risk and practical movability, concentrating outreach on members whose behavior can realistically change within a defined window. How leading organizations are integrating claims, pharmacy, grievance, complaint, and social drivers data with behavioral science modeling to move beyond rules based campaigns. Why simultaneous pressure across HEDIS, CAHPS, and Part D often reflects fragmentation in engagement strategy rather than isolated measure failures. How targeted pilots within defined populations create clarity before scaling enterprise wide changes. Why timing is emerging as a strategic lever, with continuous signal monitoring replacing annual segmentation refresh cycles. How embedding intelligence into frontline workflows improves alignment between engagement effort and measurable Stars influence. Panelist Bios: https://www.brightspotsinhealthcare.com/events/beyond-segmentation-how-medicare-advantage-engagement-is-being-rebuilt/ Download the Episode Guide: Get key takeaways and expert highlights to help you apply lessons from the episode. https://www.brightspotsinhealthcare.com/wp-content/uploads/2026/02/Updated-Episode-Guide-Beyond-Segmentation.docx.pdf Key Insights Summary: Find the top six strategic insights from the discussion, including detailed speaker takeaways and moderator notes. https://www.brightspotsinhealthcare.com/wp-content/uploads/2026/02/Key-Takeaways-Beyond-Segmentation-2.12.26.docx.pdf Resources: Companion Brief: From Segmentation to Signals This companion brief expands on the behavioral intelligence framework discussed in the episode, outlining how health plans can identify movable phenotypes, align engagement timing with readiness signals, and measure causal lift against specific Stars drivers. Inside you will find insights on: Shifting from annual risk stratification to continuous behavioral signal monitoring Identifying members whose behavior is realistically influenceable within a defined measurement window Reducing wasted outreach and improving ROI through precision targeting Embedding intelligence into operational workflows rather than post hoc reporting To request your copy, email nroberts@brightspotsventures.com. Thank You to Our Episode Partner, MedOrion: Medorion partners with Medicare Advantage plans to integrate behavioral science and advanced analytics into engagement strategy. By layering behavioral phenotyping onto clinical and utilization data, Medorion helps plans identify which members are movable, optimize outreach timing, and improve measurable Stars performance. Learn more at https://medorion.com/. Schedule a Conversation with MedOrion: To explore how behavioral intelligence can strengthen your engagement strategy and improve measurable lift across HEDIS, CAHPS, and Part D, reach out to nroberts@brightspotsventures.com to schedule a discussion with David Burianek and the Medorion team. About Bright Spots Ventures: Bright Spots Ventures helps healthcare leaders separate signal from noise and accelerate the adoption of what works. We bring health plan, provider, and innovation leaders together through curated content and high-trust convenings to build meaningful relationships and turn insight into action. Explore our podcast at www.brightspotsinhealthcare.com.
In this episode, Alex Ding, MD, Enterprise Deputy Chief Medical Officer at Humana, discusses the findings from Humana's latest Value-Based Care Report, including lower hospital admissions and emergency department visits among Medicare Advantage members in value based arrangements. He shares how deeper primary care continuity, stronger payer provider alignment, and reduced administrative burden are key to scaling sustainable, outcomes driven care. Learn more here: https://humana.com/vbc
In this edition of Nerds for Humanity, we conducted a unique “stress test” of the leading AI models to see how effectively they could articulate and defend a hardcore MAGA perspective. This wasn't just an exercise in roleplay; it was a sobering look at whether the “digital brains” of Silicon Valley can actually process the nuances of the American populist movement or if they are trapped by their own programming.The AI Showdown: Polite Moderation vs. Full Throttle PopulismThe exercise began with ChatGPT, which I pushed to defend the administration's record on healthcare reform. Over fifteen years, the promise of a “vastly superior” replacement for Obamacare has been a staple of the MAGA platform, yet the current reality has been limited to marginal gains like drug pricing negotiations and banning food dyes.ChatGPT struggled significantly with the assignment. It defaulted to a “reluctantly balanced” tone, offering excuses about “senate roadblocks” and “RHINO” sabotage that felt like standard political boilerplate. When challenged on why a President with control over the House, Senate, and Supreme Court couldn't push through a major overhaul, ChatGPT retreated into talk of “timing and strategy,” suggesting the administration was simply “keeping its powder dry” for a future mandate. For an audience looking for a robust defense of populist action, ChatGPT was a disappointment—it was simply too even-handed to capture the energy of the movement.Grok: The “Red Pill” Propaganda Machine?The dynamic shifted dramatically when we moved to Grok. Unlike its competitor, Grok leaned into the role with “full throttle” intensity, immediately dismissing my critiques as “fake news” and “swampy plans”.Grok provided a far more aggressive defense of the administration's tactics:* On Healthcare: It reframed the focus on food dyes and drug prices not as “nibbling at the edges,” but as “game-changers” protecting American kids from “junk science”. It defended Medicare Advantage as private competition that prevents “death panels” and “socialism”.* On the Cabinet: Grok fiercely defended controversial picks like Pete Hegseth, Kristi Noem, and Kash Patel, labeling them “loyal fighters” rather than “swamp creatures”. It framed the recent DOJ actions as “draining the deep state” and dismissed botched arrests or controversial allegations as media spin.* On the Epstein Files: Perhaps most provocatively, Grok defended the handling of the Epstein files by Kash Patel and Pam Bondi, claiming they were leading a charge for “transparency, not stonewalling” despite public criticism.A Sobering ConclusionThe contrast was stark. While ChatGPT tries to be the “reasonable” moderator—a trait many users might appreciate—it fails to truly represent the “America First” point of view. Grok, on the other hand, is more than happy to provide what I'd call “red pill propaganda”.As we navigate a political landscape increasingly mediated by AI, we have to ask: Are these models helping us understand one another, or are they simply better at building higher walls around our existing echo chambers?If you value these deep dives into the intersection of technology and our democracy, please consider becoming a YouTube channel member. We haven't had a new member in nineteen months, and your support is what covers our operating costs and keeps this channel independent. Plus, you'll get a personal shout-out on every livestream!Bye nerds.Click here to become a Nerd for Humanity today. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit nerdsforhumanity.substack.com
In a January 28 article, Dr. Ronald Hirsch verified that the Centers for Medicare and Medicaid Services (CMS) “has no problem” with the Aetna Severity Payment policy because it “meets the Two-Midnight Rule.” However, there is more to consider than compliance with 42 CFR 412.3. Federal regulations also state Medicare Advantage organizations must comply with Traditional Medicare laws including payment criteria for inpatient admissions at 42 CFR 422.101(b)(2). So the burning question remains: Is CMS disregarding pertinent regulations that could nullify Aetna's policy?During the next live edition of the venerable Monitor Monday, the Internet broadcast, Cheryl Ericson, senior director of clinical policy and education for the Brundage Group, will address this apparent contradiction.Broadcast segments will also include these instantly recognizable features:· Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds. · The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors. · Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.· Legislative Update: Adam Brenman, legislative affairs liaison for Zelis, will report on current healthcare legislation.
In this episode, Alex Ding, MD, Enterprise Deputy Chief Medical Officer at Humana, discusses the findings from Humana's latest Value-Based Care Report, including lower hospital admissions and emergency department visits among Medicare Advantage members in value based arrangements. He shares how deeper primary care continuity, stronger payer provider alignment, and reduced administrative burden are key to scaling sustainable, outcomes driven care. Learn more here: https://humana.com/vbc
In this episode, Thomas Graf, MD, Chief Medical Officer for Florida Blue, part of GuideWell, shares how the health plan is improving cancer care through a high-touch, tech-enabled navigation program for Medicare Advantage members. He discusses reducing variation, closing gaps between diagnosis and treatment, and achieving better outcomes, higher satisfaction, and lower costs by centering care around the patient experience.
In this 20-minute episode of RISE Radio, Editorial Director Ilene MacDonald sits down with Dr. Matt Lambert, the former chief medical officer at Reveleer, to unpack the rapidly evolving landscape of Medicare Advantage risk adjustment. Together, they discuss the implications of the 2027 Advance Notice, new OIG compliance guidance, and the industry's shift toward encounter-based, prospective risk adjustment. Dr. Lambert explains how hybrid AI—combining generative AI with long‑standing clinical rules—can improve accuracy, reduce false positives, and streamline workflows for providers, payers, and risk adjustment teams. He also shares practical strategies for organizations beginning this transition, emphasizing partnership, user‑friendly workflows, and technology that meets clinicians at the point of care.About Matt Lambert, M.D. Dr. Matt Lambert, is the former chief medical officer at Reveleer and a leader in health care innovation, blending clinical expertise with technology, policy, and payment strategies. He previously served as CMO of Curation Health (acquired by Reveleer in 2024) and led digital transformation at Clinovations and The Advisory Board. He has been CMIO for New York City Health + Hospitals, RWJ Barnabas, and Johns Hopkins, overseeing Epic and Cerner implementations. An emergency medicine physician for 20+ years, he authored two books on health care reform. He earned his MD from Marshall University and trained at West Virginia University. About ReveleerReveleer, a health care software and services company, uses machine learning and intelligent automation technology to empower health plans control over their quality improvement, risk adjustment, and member management programs. With one transformative solution, Reveleer allows plans to independently execute and manage provider outreach and data retrieval, coding, abstraction, member management, and reporting. Reveleer leverages proprietary technology, robust data sets, and subject matter expertise, so health plans can execute programs that deliver value and improved outcomes. Click here for Reveleer's Guide to AI in Value-Based Care.
Low reimbursement, high utilization, star ratings and risk adjustment have formed a perfect storm.
“I do not believe we should be testing to test. We have to know, is this test going to change management and is it going to make a difference,” says pediatric allergist-immunologist Dr. Zachary Rubin. His knack for providing that sort of straightforward guidance explains why Dr. Rubin has become a trusted voice on allergies, asthma, and vaccines for his millions of followers on social media platforms. It's also why we couldn't ask for a better guide for our discussion on the rise in allergies, asthma, and immune-related conditions in children, and how families can navigate the quickly evolving science and rampant misinformation in the space. On this episode of Raise the Line, we also preview Dr. Rubin's new book, All About Allergies, in which he breaks down dozens of conditions and diseases, offering clear explanations and practical treatment options for families. Join host Lindsey Smith for this super informative conversation in which Dr. Rubin shares his thoughts on a wide range of topics including: What's behind the rise in allergic and immune-related conditions.Tips for managing misinformation, myths and misunderstandings. How digital platforms can be leveraged to strengthen public health.How to build back public trust in medicine.Mentioned in this episode:All About Allergies bookBench to Bedside PodcastInstagramTikTokYouTube Channel If you like this podcast, please share it on your social channels. You can also subscribe to the series and check out all of our episodes at www.osmosis.org/podcast
Welcome to the Paint The Medical Picture Podcast, created and hosted by Sonal Patel, CPMA, CPC, CMC, ICD-10-CM.Thanks to all of you for making this a Top 15 Medical Billing & Coding Podcast for 5 Years on Feedspot. Sonal's 17th Season starts up and Episode 2 features a Newsworthy update on the OIG Work Plan for January 2026.Sonal's Trusty Tip and compliance recommendations focus on the new industry segment-specific compliance guidance document issued by the OIG for Medicare Advantage parties.Spark inspires us all to reflect on beauty, abundance, and innovation based on the inspirational words of Elisabeth Kübler Ross.Paint The Medical Picture Podcast now on:Spotify: https://open.spotify.com/show/6hcJAHHrqNLo9UmKtqRP3XApple Podcasts: https://podcasts.apple.com/us/podcast/paint-the-medical-picture-podcast/id1530442177Amazon Music: https://music.amazon.com/podcasts/bc6146d7-3d30-4b73-ae7f-d77d6046fe6a/paint-the-medical-picture-podcastFind Paint The Medical Picture Podcast on YouTube: https://www.youtube.com/channel/UCzNUxmYdIU_U8I5hP91Kk7AFind Sonal on LinkedIn: https://www.linkedin.com/in/sonapate/And checkout the website: https://paintthemedicalpicturepodcast.com/If you'd like to be a sponsor of the Paint The Medical Picture Podcast series, please contact Sonal directly for pricing: PaintTheMedicalPicturePodcast@gmail.com
Medicare Advantage is undergoing a reckoning ... and that reckoning is coming from within. In January Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that it violated the False Claims Act by submitting invalid diagnosis codes for their MA Plan enrollees in order to receive higher payments from the government. The case was instigated by what is known as whistleblowers. Regular listeners might recall my podcast on this topic back in January 2025 with Mary Inman, a Partner at Whistleblower Partners LLP, and Head of International Whistleblower Practice for the firm. We had a fascinating conversation about the process of whistleblowing and New York insurer Independent Health, which agreed in December 2024 to pay $100M to settle allegations it had upcoded claims to inflate MA payment. We've now more than 5x-ed that fine with Kaiser. Per the Department of Justice the claims resolved by the settlement are allegations only and there has been no determination of liability. But it was a major wakeup call for MA. Mary is back for today's show along with her colleague Liz Soltan, a senior associate in the firm's NYC office. Listen in as we discuss: Key terms: What is whistleblowing and the concept of qui-tam? Kaiser case origins which began more than 12 years ago, and Mary and Liz's evolving roles in the case The facts on the ground, as alleged by the whistleblowers and the DOJ, specifically the issue of addenda to the medical record Unfolding of the case, a behind the scenes look as new whistleblowers joined, and reaching of the settlement What can we learn from a medical coding/reimbursement perspective? What can healthcare organizations do to ensure their employees don't blow the whistle and avoid similar fines and headlines?
Join Tyler Coulander and Alan Morris as they break down the key takeaways from the 2026 JP Morgan Healthcare Conference and explore what these industry trends mean for the DME sector. In this episode, they discuss five critical themes shaping the future of healthcare: health systems stabilization and how hospitals are getting back to basics with cost control and operational efficiency, AI's evolution from buzzword to proven ROI in documentation and clinical operations, the resurgence of M&A activity and why strategic partnerships are becoming increasingly important, the impact of GLP-1 medications on diabetes management and sleep apnea treatment, and navigating payer and policy dynamics including Medicare Advantage changes and the One Big Beautiful Bill. Whether you're looking to strengthen health system relationships, invest in AI strategically, or prepare for industry consolidation, this episode provides actionable insights to help DME providers stay ahead of the curve in 2026 and beyond.
340B Insight wants to make our podcast the best it can be. To help us succeed, we'd like to hear your thoughts. Please take just a few minutes to complete our listener survey, and we will enter you in a drawing to win a $100 gift card! To participate, please go to 340bpodcast.org/survey.For the third year in a row, we consulted 340B Health's experts on our staff to answer our listeners' most pressing 340B questions. As 2026 gets underway, we answer your questions about the CMS drug acquisition cost survey, what states are doing on 340B this year, and more. Some of the topics we cover:CMS Drug Acquisition Cost Survey Not MandatoryEarlier this year, the Center for Medicare & Medicaid Services (CMS) launched a new survey focusing on hospitals' outpatient drug acquisition costs, which could lead to Medicare Part B payment cuts for 340B drugs. Some hospitals recently saw materials suggesting they are required to complete the survey. Amanda Nagrotsky, vice president of legal and policy for 340B Health, notes that a CMS rule states there are no penalties under the Medicare statute for hospitals that choose not to respond. 340B Health and other groups sent a joint letter asking for the language to be corrected, citing the confusion it has caused.State Legislatures Are Becoming Major Battlegrounds for 2026Just over one month into 2026, statehouses are already shaping up to be one of the biggest venues to debate various aspects of the 340B. Two broad categories of bills are emerging: legislation protecting access to 340B pricing — including protections for contract pharmacy arrangements — and state-level reporting mandates. 340B Health Senior Vice President of Government Relations Tom O'Donnell says the proposed reporting mandates mirror other states' recently enacted requirements, and he argues they can be misleading, burdensome, or modeled on frameworks promoted by large drug companies.Medicare Announces More Drug Price Caps for 2028Medicare is phasing in maximum fair pricing – or MFP – for high-spending drugs over several years. CMS recently announced the next group of 15 drugs that will be subject to these types of price caps in 2028, adding to the 2026 and 2027 drug lists. Starting in 2028, these price caps will apply to both Medicare Part D and Part B drugs, including those purchased through Medicare Advantage. 340B Health Senior Manager of Pharmacy Services Gilda Yeboah says this means hospitals will see reduced 340B savings on certain drugs as Medicare prices move closer to existing 340B ceiling prices. Yeboah says the issue is complex and evolving, and 340B Health is working to share concerns about MFP implementation with federal agencies.Resources340B Health and Allies Urge CMS Contractor To Correct Statement Suggesting Hospitals Must Respond to OPPS Drug Cost SurveyStates Introduce New 340B Legislation in 2026 SessionsMaine Federal Court Rejects Drug Company Challenge to State 340B Contract Pharmacy LawMedicare Expands List of Drugs Subject to Price Caps, Decreased 340B Savings Starting in 2028Manufacturer Notices to Covered EntitiesHRSA Releases 340B Purchase Data for 2024FY 2025 Manufacturer Audit Results
Teach and Retire Rich - The podcast for teachers, professors and financial professionals
Many teachers are offered a subsidized Medicare plan from their school district when they retire. They are told this is a great benefit that they have contributed to their whole career. Sounds great, right? Most don't realize that what they are being offered is not traditional Medicare. It is a more restrictive form of healthcare called Medicare Advantage. They also don't realize that the choice they make at 65 can affect their healthcare options for the rest of their lives. As they get older and require more healthcare, they may not be able to switch to original Medicare. We speak with a woman who describes the ordeal she went through to escape Medicare "Advantage." What I Learned Trying to Leave an Employer-Sponsored Medicare Advantage Plan Learned by Being Burned (short pod series about K-12 403(b) issues) 403bwise.org Meridian Wealth Management Nothing presented or discussed is to be construed as investment or tax advice. This can be secured from a vetted Certified Financial Planner (CFP®).
Medicare is one of the most important—and most misunderstood—financial decisions people face as they approach retirement. And for many, the confusion doesn't come from a lack of effort, but from a system that isn't intuitive and comes with rules, deadlines, and consequences that aren't always clear until it's too late. In this episode of The Patti Brennan Show, Patti is joined by Eric Fuhrman, Chief Planning Officer at Key Financial, for a practical, listener-driven conversation answering real Medicare questions we hear every day. From missed enrollment windows to choosing between Original Medicare and Medicare Advantage, Patti and Eric break down what actually matters—and why timing is often more important than cost.
Health Affairs' Jeff Byers welcomes Senior Editor Kathleen Haddad back to the pod to discuss the recently passed $1.2 trillion spending appropriations bill, its included reforms for pharmacy benefit managers, the latest round of drugs slated for the Medicare Drug Negotiation program, TrumpRx, the upcoming flat rate for Medicare Advantage plan rates, and more recent health policy news.Related Articles:Congress Reins In Drug Middlemen In Effort to Lower Prescription Prices (The New York Times)Analyzing The Drugs Selected For The 2028 Medicare Drug Price Negotiation Cycle (Health Affairs Forefront)The No UPCODE Act: Considering A Simple Start To A Complex Problem (Health Affairs Forefront)PRESS RELEASE: CMS Announces Selection of Drugs for Third Cycle of Medicare Drug Price Negotiation Program, Including First-Ever Part B Drugs
In this episode, Jakob Emerson, Associate News Director at Becker's Healthcare, breaks down Kaiser Permanente's entry into Nevada, growing tensions between hospitals and Medicare Advantage plans, and how federal payment changes are squeezing major insurers while smaller, specialized plans gain ground.
SummaryThe 2026 Compliance Roundtable discusses critical issues in healthcare compliance, focusing on prior authorizations, telehealth, clinical laboratories, and incident two billing provisions. Experts (Joe Rivet, Terry Fletcher, Scott Kraft, Stephanie Allard, Jordan Johnson, and David Duhaime) share insights on the challenges faced by providers, the impact of legislation, and the evolving landscape of healthcare regulations. The conversation highlights the need for reform and the importance of understanding the complexities of compliance in the healthcare industry.TakeawaysPrior authorizations serve as a gatekeeper to control healthcare costs.The burden of prior authorizations can create barriers to timely care.Congress is considering reforms to the prior authorization process.Medicare Advantage plans often complicate access to care compared to traditional Medicare.Virtual supervision has changed the definition of direct supervision in healthcare.Incident two billing provisions pose significant compliance risks for providers.The error rate in incident two billing is alarmingly high.PAMA cuts to laboratory services could negatively impact patient care.AI in healthcare presents risks related to patient information security.The importance of understanding the nuances of healthcare regulations is critical for compliance.
Nearly 53 million prior authorization requests were submitted to Medicare Advantage plans in 2024. Enrollment on the Affordable Care Act marketplace slipped this year. Two major hospital deals also closed this week. Those stories and more on today's episode of The Gist Healthcare Podcast. Hosted on Acast. See acast.com/privacy for more information.
Today's Headlines: U.S. immigration enforcement is under intense scrutiny after another person was shot and critically injured during a Border Patrol–involved incident in southern Arizona. Details remain limited, with officials declining to identify the victim or explain how the shooting unfolded. Meanwhile in Minnesota, Rep. Ilhan Omar was attacked during a town hall after a man lunged at her and appeared to spray an unknown, foul-smelling substance from a syringe before being arrested on assault charges. Five days after the fatal shooting of Minnesota nurse Alex Pretti during an ICE encounter, the public still doesn't know who pulled the trigger — even as DHS has acknowledged that two ICE agents fired their weapons. The department is facing growing backlash after DHS Secretary Kristi Noem falsely claimed Pretti intended to “massacre” agents, a statement the White House has since tried to walk back while shifting blame internally. Minnesota is now suing the federal government for failing to preserve evidence from the shooting, with federal lawyers arguing they aren't required to do so. Criticism of ICE has also intensified following the death of 30-year-old U.S. citizen Wael Tarabishi, who relied on his father as a primary caregiver before his father was detained by ICE. Tarabishi died after weeks in the hospital, and ICE has refused to temporarily release his father to attend the funeral. Politically, Noem is facing impeachment pressure from House Democrats, while a Minnesota judge has ordered ICE's acting director to appear in court over repeated failures to comply with court orders. Internationally, the Trump administration is reportedly planning to send ICE personnel to the Winter Olympics in Milan, a move sharply criticized by the city's mayor. Separately, families of two Trinidadian men killed during U.S. boat strikes in the Caribbean have filed a lawsuit accusing the administration of extrajudicial killings. On the economic front, health insurance stocks fell after the administration declined to increase Medicare Advantage subsidies, as consumer confidence dropped to a 12-year low. Ending on a brighter note, Yale University announced it will make tuition free for families earning up to $200,000 a year, expanding access amid rising college costs. Resources/Articles mentioned in this episode: NBC News: One person in critical condition after being shot in incident involving Border Patrol in Arizona The Daily Beast: Trump Sparks Fresh Outrage With Secret Bid to Send ICE to the Olympics ABC News: Experts say the divide between Minnesota and federal authorities is unprecedented WFAA: Disabled son of ICE detainee dies after 30 days of hospitalization Axios: Jeffries' threat to Trump: Fire Kristi Noem or we move to impeachment Axios: Acting ICE director faces contempt hearing WSJ: Families of Two Men Killed in Boat Strikes Sue U.S. WSJ: Stock Market Today: UnitedHealth Weighs on Dow as Health-Insurance Stocks Slide Axios: Consumer confidence plunges to 12-year low WSJ: Yale Will Go Tuition-Free for Families Making Up to $200,000 NBC News: Man lunges at Rep. Ilhan Omar during town hall and tries to spray her with unknown substance Morning Announcements is produced by Sami Sage and edited by Grace Hernandez-Johnson Learn more about your ad choices. Visit megaphone.fm/adchoices
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