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Tag: Payers

Medicare Policy Shouldn’t Be Made in the Shadows

As a rheumatologist, I treat rheumatoid arthritis (RA) and other complex autoimmune diseases. If you have or happen to develop one of these diseases, I am thankful that science has delivered amazingly effective targeted therapeutics and biologics in recent decades. While highly effective, these treatments come with a high economic cost, so I have grown accustomed to daily battles with commercial insurance plans to get working-age patients the treatments they need. While horror stories abound regarding commercial insurers, Medicare has traditionally been a more predictable partner for my older patients. Medicare reimbursement is low — an issue worthy of a separate commentary piece — but comes on time, typically without the hassle and administrative delays of prior authorizations, assuming we use our therapeutics within FDA-approved dosing and indications.

On top of these existing challenges here in the Midwest, providers recently won a battle we did not expect to have to fight with a Medicare administrative contractor (MAC). The story deserves scrutiny from legislators and regulators nationwide.

Medicare beneficiaries rightly assume, as have I, that policy spells out the services they are entitled to receive. Lawmakers in Congress establish patients’ benefits in law, while the Centers for Medicare & Medicaid Services (CMS) develops the national rules and policies to implement them. MACs fit into this process by administering those rules regionally (with some discretion), but they are not supposed to privately create new substantive conditions of payment.

Recently, the MAC overseeing Kentucky and Ohio began auditing and denying claims for intravenous Orencia, a biologic drug used to treat RA, citing a “lack of medical necessity.” The policy affected more than a hundred patients who had mostly been on Orencia for a decade or more. These patients were forced to stop or delay treatment or switch therapies, which resulted in serious RA flares. MAC administrators had decided that most patients on intravenous Orencia, covered under Medicare Part B, should instead receive subcutaneous Orencia, covered under Medicare Part D and often at substantially higher out-of-pocket cost.

The decision was made without a formal notice-and-comment process. In fact, this requirement does not even appear in the Medicare guidance cited for this decision. Worst of all, it effectively forced dozens of patients off a life-changing therapy.

Thanks to outreach from clinicians, national advocacy organizations, angry patients, and congressional representatives, this policy was walked back. Or at least, we think so. There was no announcement of a reversal. Instead, the MAC covering Kentucky and Ohio quietly revised a fact sheet on its website, removing language that preferred subcutaneous over intravenous dosing.

This whiplash has been devastating to my own small clinic, however, as the MAC continues to withhold the equivalent of roughly three payrolls’ worth of payments for treatments we rendered in good faith during this period. They have also not answered repeated inquiries about whether denials issued under the now-removed standard will be reversed.

This situation exposed several problems that need to be addressed before this happens to other MACs, Medicare beneficiaries and clinicians:

1. The current system allowed one medical director’s opinion to acquire the force of Medicare policy without an effective check. This violates the Supreme Court’s decision in Azar v. Allina, which limits the government’s ability to create substantive Medicare payment standards through informal guidance. Yet it still took months of work, worry, and countless hours distracted from providing clinical care to get the issue elevated to a level where the policy was reconsidered.

2. There is inadequate accountability and little transparency within MAC operations. After an initial call with the MAC medical director to raise this issue, we went for weeks with response and no clue as to where our appeal stood. Providers didn’t know how to “correctly” care for our affected patients. When the disputed language did quietly disappear from the fact sheet, there was no public explanation, formal announcement, or directive regarding claims already denied.

3. There is no clearly identified chain of command to move a critical issue of patient harm from a regional MAC to CMS. As an experienced advocate, I leveraged my relationship with my congressional representative and the American College of Rheumatology to elevate this issue to CMS, but what if I hadn’t had those relationships? Our system should not require physicians to become experts in Medicare law and policy just to ensure the Medicare system follows its own rules.

Medicare beneficiaries deserve better. While in this case we’ve been able to protect access to intravenous Orencia, this experience exposed flaws that extend far beyond one drug or one MAC contractor. We should all be concerned that MACs are increasingly making unilateral decisions that negatively impact patient access. Medicare policy should be transparent and include appropriate notice and stakeholder input. And when a contractor gets it wrong, there should be a clear and rapid way to stop the harm to patients, their relationship with their doctor and the doctor’s practice. A patient’s access to Medicare-covered care should never depend on whether their physician can find someone in Washington willing to intervene. Something must change.

Author bio:

Dr. Chris Phillips is an American College of Rheumatology leading rheumatologist and owner of Paducah Rheumatology.

Photo: Stas_V, Getty Images

October 13, 2026
Pediatric Innovation Isn’t a Small-Market Problem, It’s an Incentive Problem

The case for investing in children’s health should be self-evident. As a society we have a responsibility to invest in the next generation, and few investments carry greater long-term benefit than helping children reach their healthiest possible futures.

When we diagnose and treat conditions early, we do more than improve a child’s health in the moment. We are altering the trajectory of their entire life: development of their personal confidence, resilience, mental wellbeing, learning capacity, and in many cases, also reducing decades of downstream public and private healthcare costs.

Yet, pediatric innovation remains chronically and systemically undervalued in healthcare.

That is not because the market for pediatric healthcare is small, it is because the incentives are misaligned. The cost of treating a child’s condition is incurred immediately. However, when early pediatric interventions are effective, their benefits often compound over decades.

No single stakeholder is incentivized to properly and accurately consider the full return on early pediatric interventions and support their adoption. The average tenure of a person staying on the same health plan is two to three years. As a result, private insurers are focused on cost savings that will be realized within that time frame, which for pediatric treatments especially, may only represent a small proportion of the overall benefit.

On the public insurance side, children are largely covered by Medicaid, and while pediatric health is a central tenet of Medicaid’s mission, the program is too often hamstrung by its structure. Unlike Medicare, which is entirely financed at the federal level, Medicaid is jointly financed between the federal government and each individual state. The program is often left underfunded, as its budget is subject to annual appropriations decisions by state legislators who have limited fiscal flexibility. Priorities are constantly changing, making long-term planning next to impossible for Medicaid decision makers.

That misalignment has consequences well before a new technology ever reaches a payer’s desk. When long-term pediatric outcomes are undervalued, the ripple effect moves backward through the entire innovation pipeline, shaping what gets funded, what gets studied, and what ultimately reaches patients.

Investors, wary of uncertain reimbursement and lower near-term returns, often direct capital toward adult indications with clearer paths to market. Drug and device developers may follow the same logic, deprioritize pediatric programs or skip pediatric studies. The result is a self-reinforcing cycle: limited investment leads to fewer pediatric success stories, which then reinforces the false perception that pediatric markets are too small or too risky to justify meaningful investment.

This is why pediatric innovation in healthcare must be evaluated differently.

Payers should require robust clinical evidence to make responsible coverage decisions. But the decision making framework for pediatric products should reflect the unique realities of childhood conditions: the value of early intervention, the long-term costs and consequences of undertreatment, and the potential for a therapy to alter a child’s life path before preventable challenges become permanent ones.

Policy leaders should also examine whether existing pediatric coverage pathways are actually keeping pace with modern innovation. In theory, we already have a powerful mechanism for this: the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Under federal law, EPSDT mandates that Medicaid-enrolled children receive all medically necessary services to correct or ameliorate important pediatric conditions, regardless of whether those services are explicitly covered in a state’s standard plan. It is a visionary policy designed to ensure that no child is left behind by the structural limitations of our healthcare system. In practice, awareness of the EPSDT benefit among Medicaid beneficiaries is low, and Medicaid plans need to do more to streamline the approval process for EPSDT-covered technologies.

Investing in pediatric care is not simply a moral imperative. It is one of the most practical long-term investments the healthcare system can make.

The question is not whether children’s health is worth the investment, that answer is self-evident. The real question is whether our healthcare ecosystem has the foresight to correct these incentive structures before another generation of children bear the cost of our delay.

Photo: Suriyapong Thongsawang, Getty Images

Scott Xiao

Scott Xiao is the co-founder and CEO of Luminopia, a therapeutics company developing software-based interventions at the intersection of ophthalmology and neuroscience. Luminopia’s lead product is a novel FDA-cleared prescription digital therapeutic for amblyopia, the leading cause of vision loss in children, affecting approximately 1 in every 30 children. Scott founded Luminopia after leaving Harvard University at age 17, inspired by a classmate’s experience with amblyopia and the limitations of traditional treatment. He has led the company from early development through clinical validation, regulatory clearance and national commercialization, with the therapy now prescribed to more than 12,000 patients by 1,300+ providers at 600+ top eye institutes, children’s hospitals and private practices. Under his leadership, Luminopia became the first FDA-cleared virtual reality–based treatment for any medical condition. Scott has also spearheaded Luminopia’s real-world evidence strategy, including the development of the PUPiL Registry, which has been instrumental in securing both FDA label expansion and major payer coverage decisions. Scott has been recognized on Forbes 30 Under 30 list in Healthcare, MIT Technology Review Innovators Under 35, and Modern Healthcare’s 40 Under 40. Luminopia was also named one of TIME’s Best Inventions of 2023. Scott is a strong advocate for the role of technology in improving patient engagement and outcomes and is focused on expanding Luminopia’s pipeline to address additional neuro-visual conditions, including strabismus and vision loss following stroke or traumatic brain injury.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.

October 12, 2026
Trilliant Health: Misaligned Incentives Are Undermining US Healthcare

The U.S. healthcare system is facing a tragedy of the commons, in which each stakeholder is incentivized to act in their own self-interest. That is the focus of Trilliant Health’s report released on Tuesday.

Trilliant Health is a healthcare analytics and market research firm. The report examines six trends drawn from Trilliant’s claims database, price transparency data and government and industry sources.

“The six different trends that we cover all really tie into the tragedy of the commons, which ultimately is this idea that incentives reward individual actors for their behavior that the collective cannot sustain, and this is just something that we see throughout our healthcare system,” said Trilliant Health’s Chief Research Officer Allison Oakes. “Unfortunately, everyone in the healthcare system is really incentivized to be managing and sort of optimizing for their own revenue and profits, and no one is entirely responsible for actually improving health.”

The six trends include:

1. The healthcare system isn’t functioning as a system: About 70% of Americans believe the healthcare system has major problems or is in a state of crisis, and healthcare costs are continuing to rise. Employee deductibles and premiums are increasing faster than wages and inflation.

“Americans are more concerned about affording healthcare than they are about gas, housing, utilities, and groceries. … I think this affordability issue is really starting to hit a breaking point,” Oakes said.

2. Population unwellness is a systemic failure: The U.S. population is increasingly becoming unwell due to poor diet, physical inactivity and social isolation. However, healthcare incentives continue to prioritize sick care over prevention.

Pediatric behavioral health visits for pervasive developmental and anxiety disorders increased substantially from 2019 to 2025. In 2025, 6.4% of children were taking five or more medications, and more than 10% of patients in 11 states received opioid prescriptions from three or more providers.

3. Disconnect between demand and supply: Behavioral health and primary care physician supply is lacking. By 2038, the overall physician supply is projected to meet just 87.7% of demand, with adult psychiatrists and primary care physicians facing the largest shortages at 49.8% and 80.4% adequacy, respectively.

In addition, advanced imaging and behavioral health visits grew faster than primary care from 2019 to 2025, while consumers increasingly turned to self-testing and other nontraditional approaches to meet their health needs.

4. Value is not incentivized, nor measured or managed: CMS uses more than 800 active quality measures, but only 27% are tied to outcomes. In addition, hospital negotiated rates show little correlation with quality, with higher prices not necessarily associated with lower 30-day mortality rates, the report found.

5. Fraud, waste and abuse: Misaligned incentives are contributing to fraud, waste and abuse, the report shows. From 2019 to 2024, the number of for-profit hospices rose 11.2%, and nonprofit hospices fell 2%. In addition, for-profit hospices saw a 13.7% Medicare margin in 2023, versus -1.3% for nonprofits.

6. Negative-sum game: New medications are challenging the U.S. healthcare system’s traditional reliance on higher patient and procedure volumes to drive revenue.

The growing use of drugs such as GLP-1s and SGLT2 inhibitors has coincided with declines in certain procedures, suggesting that medications could increasingly replace or reduce demand for costly interventions.

Photo: champc, Getty Images

October 7, 2026
Constant Vigilance is the Watchword for Healthcare AI Governance
A webinar moderated by MedCity News Editor-in-Chief Arundhati Parmar delved into findings of the recently published Healthcare AI Readiness Index. Panelists discussed how best to balance AI adoption, governance, how to scale AI at healthcare institutions and best practices for doing so. Sponsored by Cotiviti, the webinar included perspectives from Cotiviti CIO Sean Warren and Thomasina Anane, Associate Vice President, Enterprise Analytics, with the Alliance of Community Health Plans.

Cotiviti turns fragmented data into actionable insights. It helps healthcare organizations reduce waste, fraud, and abuse, and works with them to simplify their operations.

“In many ways, what we’ve become is the connective tissue that helps healthcare work more efficiently across all of the payers, providers, and other stakeholders,“ Warren said.

Anane referenced a recent annual meeting of ACHP, which included a candid discussion on AI governance.

“One theme that really came through clearly is that AI governance has to start well before deployment and evolve along the use case. Many of our health plans are grappling with issues like: What is my state saying about AI use? What does that look like federally and what does that look like as a health plan?….What data are actually involved? What decision is being influenced? What happens when the output is wrong?”

The biggest challenge with AI governance in a clinical and payer setting is the need for constant vigilance, a point made by both Anane and Warren.

“Deployment is really not the finish line,” Warren said. “It’s constant follow-up, constant security checks, and we have a lot of human-in-the-loop and human oversight with observability. It’s ten times more important when we add AI to the mix to be able to know what that AI is doing. Do you have the guardrails around what the AI is doing in your environment? Do you have the ability to undo it? Do you have the ability to follow and trace every transaction?”

The webinar discussion also touched on other issues such as:

What should leaders assess before moving an AI use case from pilot to enterprise deployment?

Are traditional vendor questionnaires and point-in-time assessments still sufficient?

What is driving shadow AI use?

Important considerations for Chinese AI models and frontier AI models.

Why might traditional cybersecurity controls be necessary, but insufficient in the new threat environment healthcare organizations face?

To access a recording of the webinar, fill in the form below:

Photo: Sandwish, Getty Images
October 7, 2026
PBM Transparency Is Still Too Opaque — How Can Employers Rein In Drug Costs?

Healthcare premiums are expected to jump another 9% in 2027. The cost of care is reaching a point where some are forgoing health insurance entirely. Health plans and employers are looking for a cost-relief valve wherever they can.

Earlier this year, Congress moved to lower pharmaceutical costs, passing the Consolidated Appropriations Act of 2026 (CAA of 2026). The bill included pharmacy benefit management (PBM) reforms that would add greater transparency to the process these organizations use to price prescription medications. The legislation mandates that PBMs submit detailed semi-annual reports to employers about their rebate prices and overall spending. This has largely been celebrated as a major win for the healthcare industry. For employers, it’s a wait-and-see game, as its impacts won’t be felt until 2027.

Ahead of the CAA of 2026 and due to settlements with the Federal Trade Commission, PBMs are shifting how they manage their revenue. Some are telling their investors directly that, despite added regulation, they expect revenue to remain the same. PBMs are doing this by restructuring how revenue is captured and keeping it within their own ecosystem under a different label. This undercuts the transparency the legislation aimed to create—before it has even taken effect.

This means employers are trying to comparison shop in a market where all the price tags are hidden. And most can’t simply switch PBMs to find better pricing for their members. They face two structural challenges:

● Contractual hurdles: Most PBM contracts require lengthy notice periods for termination. Larger employers with custom contract terms often face notice requirements of up to 12 months. In practice, that means the decision to leave must be made before most employers have even begun evaluating alternatives. And leaving a contract early means an employer who received a rebate reconciliation payment or a performance bonus may be required to return it upon early termination, essentially penalizing them for exercising their right to change vendors. Rebate reconciliation timing creates an additional financial exposure. Most PBM contracts include a rebate reconciliation period of 12 to 18 months following contract termination, during which the PBM retains the right to adjust previously reported rebate figures.

● Data blockades: Upon termination of a PBM contract, employers are entitled to their claims data, but the timeline, format, and completeness of that data transfer are frequently governed by contract language that favors PBMs. Common tactics include:

○ Requiring expensive translation of proprietary data before a new PBM can intake it, potentially creating months-long implementation delays.

○ Charging data extraction fees that are not disclosed until termination is initiated, sometimes running into tens of thousands of dollars for larger plan populations.

○ Delaying the transfer of member eligibility files and prior authorization histories, which creates coverage gaps and member disruption at the moment of transition. For example, say a member is mid-therapy on a specialty drug with an active prior authorization; that authorization does not automatically transfer to the new PBM. The incoming PBM must re-adjudicate it, and during that window the member may face a coverage interruption.

Switching PBMs is inherently disruptive, time-consuming, and designed to create transition friction. However, there are times when finding a better-fit PBM outweighs the roadblocks. If that time comes, here are five key areas employers should consider to lower costs for their members:

● A strong foundation: Choose a PBM that employs rigorous clinical management, prior authorization, and formulary management practices. These are the primary mechanisms through which a PBM controls drug mix, ensures clinical appropriateness, and prevents unnecessary spend.

● Specialty drug management: This is often the highest-yield starting point. Strategies including specialty PBM carve-outs, site-of-care optimization, and alternative funding programs can reduce specialty spend by 25% to 40% in some categories, based on documented employer case results.

● GLP-1 management: Obesity-related GLP-1 clinical management programs that pair pharmacist coaching with behavioral support have shown reductions in ongoing GLP-1 utilization while preserving outcomes. Poorly structured programs may only shift costs rather than reducing them.

● Biosimilar-first policies: Employers should check their PBM contract for any biosimilar-first policies that may be in place for applicable drug categories. In many incumbent PBM formularies, branded biologics remain preferred due to rebate economics, even when a biosimilar is clinically equivalent and significantly less expensive.

● Transparency rules: Transparency requirements from the CAA of 2026 will compel greater fee disclosure, and employers who understand what those disclosures mean will be better positioned to act on them. The challenge is that most employers are not currently equipped to interpret what they see. That is where independent pharmacy advisors and employer-based coalition models can play a significant role.

While momentum is growing to enact more transparency across the healthcare industry and more specifically within the PBM space, the current disclosure rules still fall short of what employers need to lower costs. True transparency means employers can see every dollar that flows through their PBM: where it originates, who retains it, and on what basis. That means:

● Rebates are passed through in full and disclosed at the claim level

● A PBM’s specialty pharmacy is not receiving preferential routing that generates undisclosed margins

● Administrative fees are itemized and auditable

● Formulary decisions can be traced to clinical rationale rather than manufacturer economics

Healthcare continues to become more expensive, but employers don’t have to be passive participants. Even in an opaque PBM landscape, they can demand greater accountability and make more informed decisions that lower costs and improve care.

Photo: OsakaWayne Studios, Getty Images

Christine Johnston

With over 20 years of experience in the PBM space, Christine Johnston
is an accomplished pharmacy benefit leader and consultant with a demonstrated history of managing costs and improving processes for plan sponsors. She is the General Manager of MacroHealth‘s Pharmacy Solutions Marketplace and was previously the co-founder and president of Foundational Pharmacy Strategies, which was recently acquired by MacroHealth. Prior to that, Christine led a small pass-through PBM. Christine is dedicated to lowering the overall cost of care to ensure individuals do not face difficult trade-offs between essential needs and necessary medications.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.

October 7, 2026
From Distributor to Disruptor: Amazon’s Healthcare Flex
Could this be Big Tech’s ultimate healthcare flex? For years, Amazon’s ambitions in this $4 trillion market were focused on distribution: acquire a pharmacy here, a primary care network there, and offer convenience.

But more recently, rather than deploying capital to expand its fulfillment engine, Amazon exercised its cloud and AI muscle to launch tools that enable it to be a “front door” for consumers and patients. From the looks of it, the e-commerce giant has shifted, from competing for a piece of the healthcare journey to collapsing the entire journey into one company.

In any case, pharma commercialization teams may need to think about Amazon less as a new distributor and more as a disruptor of how patients, prescribers, and payers connect.

Analyzing the moves

Big Tech has upended many industries, but the highly regulated and complex healthcare industry has seemed impervious to their influence. Judging by Amazon’s most recent forays, however, this sector may not represent an innovator’s “white whale” for much longer.

Amazon has closed the “last mile” between writing a prescription and filling it. At One Medical clinics (Amazon’s primary care venture), pharmacy kiosks now let a patient walk out of an appointment with medication in hand, filled by the same company that just diagnosed them. Its oral GLP-1 management program, a recently introduced offering, takes this even further.

This year, One Medical also launched an AI-enabled assistant, with access to test results, medical history, and more. The AI agent, dubbed Health AI, can help book medical appointments or provide medical information, such as an explanation of lab results. This clearly strengthens One Medical’s abilities as a provider and can help in enhancing the patient experience all the way through drug dispensing.

More critically to pharma, Amazon’s Health AI also automatically applies manufacturer coupons and copay assistance programs for eligible patients. On the HCP side, Amazon’s integration with DoseSpot and eNavvi places patient net out-of-pocket at the point of prescribing.

Health AI subsequently moved beyond the One Medical app, embedding directly into Amazon.com and its mobile app, marking the first time the tool has been available at scale to general consumers, and further enmeshing the patient experience into the overall Amazon environment. These offerings are available to anyone, regardless of being a One Medical member.

4 potential shake-ups

The result: Screening, prescribing, fulfillment, and ongoing renewal all happen inside one Amazon-run loop. No outside touchpoint is required.

That loop doesn’t just change where a patient enters the system and picks up a prescription. It changes the nature of a healthcare “provider,” how care is delivered (including drug fulfillment), and who sees the full picture of a patient’s care.

In other words, this shift isn’t just a single disruption; it’s four separate ones. Here’s the “where” and “how” of those potential shake-ups:
- The HCP relationship: Who manages a condition over time, not just who writes the first script?
- Channel and patient experience: Who owns the point of fill, and how seamless is the drug-fulfillment experience?
- Price transparency and patient OOP: How much of a role does real-world price play, for both prescribers and patients, and how do coupon and copay assistance programs need to adapt?
- Data visibility: Does the full patient journey, from diagnosis to refill, sit outside the purview of traditional pharma data sources, or is it somehow still captured?
The four categories aren’t equally mature. And that has real implications for where pharma commercialization teams focus first.

Where pharma should focus

The first two of the above categories are already live with the GLP-1 program. That is, ongoing management of a chronic condition now sits inside Amazon’s own clinical protocol, not a patient’s existing PCP or specialist. And prescribing, fulfillment, and refill take place in a channel pharma doesn’t traditionally call upon.

GLP-1 is a favorable starting point for this model because it’s heavily consumer-driven and manageable in primary care, so the loop doesn’t need specialist judgment to run. And the GLP-1 cash-pay models give Amazon room to control pricing directly. Moreover, weight-loss management is a long-term, recurring relationship, which is exactly the kind of retention Amazon’s model is built for.

Beyond the cash market, Amazon’s ability to automatically apply coupons and copay assistance offers the opportunity for accelerated product uptake, accompanied by significant downside risks to product gross-to-net.

If your brand touches a condition that could be managed this way, GLP-1 isn’t a case study to read with curiosity. It’s a preview. Teams should be asking if and how this loop affects prescribing and fulfillment for their therapeutic area; that’s the immediate gap to close.

Conditions that depend on specialist diagnosis, complex or in-clinic administration, or those with reimbursement complexity, are a much harder fit for this model (at least for now). The therapeutic areas to watch first are protocol-friendly, primary-care-managed, chronic, and with a cash-pay market underneath.

Payers and data

Amazon’s impact on the payer space is at an earlier stage, but the signals are worth tracking closely. Amazon has already become the exclusive home delivery pharmacy for select PBM partners, including its own employee health plan. While that’s a narrow footprint today, whether it stays narrow or expands to further erode the traditional PBM mail-order business is the open question. Every new deal is a data point worth logging.

Data visibility is the slowest mover of the four categories, and possibly the hardest to predict. Cash-pay markets already have data holes. Adherence and outcomes in these markets have always been harder to capture, since the transaction doesn’t run through the claims and pharmacy systems pharma is used to watching.

The bigger exposure is what happens if this extends into broader chronic disease management. Even losing part of a patient’s journey, say the fulfillment and refill half, is enough to break the continuity pharma relies on for adherence programs and tracking the various outcome measures of marketed treatments.

Other industries offer a useful, if uncomfortable, reference point. Retail went through its own version of this: Vertically integrated fulfillment that started as a convenience play eventually became infrastructure that competitors couldn’t easily match on price or speed.

That pattern is worth keeping in mind, not as a prediction of exactly how this plays out in life sciences, but as a reminder that the “early and narrow” phase doesn’t stay that way indefinitely.

None of this is a call to panic. It’s a case for watching the right signals. The clearest one: which therapeutic area Amazon’s loop expands into next.

Photo: undefined undefined, Getty Images

Adrienne Lovink

As CEO, Adrienne Lovink is leading Beghou’s next phase of growth and building on its reputation as a trusted commercialization partner in life sciences. She is focused on expanding into new areas of client demand; advancing the firm’s data, AI, analytics, and technology innovation; and investing in its people and culture. Adrienne has over 25 years of experience partnering with pharmaceutical and medical device companies to advance commercialization, market access, forecasting, digital health, real-world data, and advanced analytics, including as a Partner at Trinity Life Sciences and Global Head of Real-World Data and Advanced Analytics at DRG / Clarivate.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.
October 7, 2026
Hidden Risks and Costs of Maternal/Infant Health that Health Plans Miss

Pregnancy and neonatal care are complex healthcare journeys requiring specialized insight to address and navigate the unique challenges involved. From clinical risks to social and non-clinical drivers of health, member engagement to the potential for overbilling, the need to control costs and improve outcomes has never been greater.

Access to reliable transportation can be an overlooked but critical barrier to maternal care. A missed prenatal visit can lead to complications that send the mother into labor well ahead of the due date, leading to a prolonged NICU stay. A long NICU stay can generate high medical costs, not to mention the stress on families potentially facing substantial medical expenses, the future health of the mother and child, and billing complexities. ProgenyHealth sees the bigger picture and understands how to work with health plans to manage these risks.

A new report from ProgenyHealth offers a window into how the business works with commercial and Medicaid health plans to close gaps in maternity and NICU care management that traditional programs overlook. Health plans benefit from the company’s experience and insight to address these challenges.

The process involves turning information gathered from extensive claims and clinical data, as well as case management interactions, into timely interventions that enhance the member experience, improve outcomes and manage costs. To download the white paper Beneath the Surface: The Hidden Risks and Costs Commercial and Medicaid plans Are Missing, fill in the form below:

Photo: Morten Falch Sortland, Getty Images

October 6, 2026
Trump Administration Announces $90 Payments to Help Cover Medicare Part B Premiums

On Friday, President Donald Trump announced that the federal government is making one-time payments of $90 per person for more than 20 million people to help them pay for Medicare Part B premiums.

These payments are coming from the Medicare Improvement Fund, which is meant to make improvements to the Medicare fee-for-service program and has been given $2 billion by Congress. Eligible seniors will receive the payment via a direct deposit in early October.

According to a fact sheet, those whose premiums are paid by Medicaid or who pay an Income-Related Monthly Adjustment Amount don’t qualify for payments. Those enrolled in private Medicare Advantage plans also aren’t eligible.

This one-time payment likely won’t do much when it comes to offsetting rising healthcare costs, noted Juliette Cubanski, vice president and director of the Program on Medicare Policy at KFF, in a recent post.

Currently, Medicare’s standard Part B premium is $2,435 and is expected to increase by $79 annually for 2027, according to KFF. This means that “this increase alone would consume most of the $90 payment,” Cubanski noted. In addition, beneficiaries will likely see healthcare costs rise in other ways, such as deductibles and cost sharing for medical and drug benefits.

Cubanski also compared these $90 payments to a similar proposal announced by Trump ahead of the 2020 election, which involved a $200 drug card to offset out-of-pocket drug costs for Medicare beneficiaries.

“The cards were to be provided under a Section 402 demonstration designed to test whether lowering out-of-pocket drug costs would improve medication adherence, reduce unnecessary health care use, and lower Medicare spending,” Cubanski said. “Ultimately, the drug cards were never sent, amid questions about the design of the experiment and its nearly $8 billion projected cost.”

Cubanski noted that the $90 payments will mostly deplete the Medicare Improvement Fund.

These payments also come after the Trump administration announced in September $500 refunds per person to nearly 1 million Americans with Affordable Care Act coverage. One healthcare expert previously told MedCity News that these checks will do little to address healthcare affordability.

“There is no question that $500 matters to a family struggling to pay its bills, and Americans are struggling,” said Dr. Adam Brown, an emergency physician and founder of ABIG Health. “Healthcare costs are a significant part of that burden. But we have to put this refund into context. For someone paying the full cost of an ACA plan, $500 doesn’t even cover one month’s average premium. … Ultimately, we shouldn’t confuse a check with a healthcare affordability strategy.”

Photo: DBenitostock, Getty Images

October 5, 2026
Strengthening Dental Payment Integrity Through Smarter Claim Editing

Fraud, waste, and abuse (FWA) continue to challenge dental plans as overtreatment, miscoding and inappropriate billing practices drive unnecessary costs and weaken payment integrity. For dental payers, the stakes extend beyond financial losses: these issues can also expose members to unnecessary procedures and consume benefits that should be preserved for appropriate care.

With an estimated $198 billion spent on dental care in 2025, and approximately 3–10% of these payments lost annually to FWA, dental payers need more effective ways to identify suspect claims before payment. A more advanced approach to dental claim editing can help plans improve payment accuracy, surface emerging risk patterns, and better protect plan resources and member benefits.

By pairing automated dental claim editing with expert clinical, documentation, and coding review, plans can address FWA more proactively to prevent errors while reducing disruption that often accompanies postpay recovery efforts.

What’s driving FWA in dental billing

Dental billing gives providers more discretion and fewer guardrails than medical billing. A few key factors drive FWA risk, including:

⒈ Limited pre-authorization requirements. Medical procedures billed to health plans often require pre-authorization tied to a documented diagnosis. In dental practices, non-surgical procedures like crowns get billed and coded at the discretion of the dentist with no comparable check before the claim is submitted.

⒉ Consolidation and profit-driven performance goals. As more dental practices are acquired by larger organizations, providers are increasingly pressured to align with stakeholder performance targets. This can push practices towards more standardized treatment approaches rather than individualized care plans that are tailored to the needs of the patient.

⒊ Heightened exposure in Medicare Advantage. MA plans can be especially vulnerable to overpayments. Some plans may cap dental benefits, but others place no limit on procedures a provider deems essential—creating an opening for bad actors to overtreat. A patient with a $2,000 dental allowance, for example, may be steered toward unnecessary procedures simply to exhaust the benefit.

⒋ Outside consultants may advise on revenue, not clinical best practices. Many dental offices engage consultants focused on hitting revenue goals, often without grounding in clinical or billing standards. The result is predictable: staff are coached to bundle procedures—billing for a build-up alongside every crown, for instance—even when the build-up is unnecessary, or in some cases, never performed.

Operational impacts of dental FWA

FWA is estimated to cost the U.S. healthcare system hundreds of billions of dollars annually, and dental billing contributes to that burden through overtreatment, miscoding, and other inappropriate reimbursement practices. For dental plans, even a small percentage of improper payments can translate into meaningful losses, especially as claim volume and coding complexity continue to rise.

The downstream effect is broader than overpayment alone: FWA contributes to higher administrative cost, unnecessary utilization, and pressure on premiums and plan resources.

Individual cases of overtreatment such as unnecessary crowns, buildups or periodontal procedures can be costly on their own. At scale, those patterns can create substantial financial and operational impact for dental payers.

Beyond direct overpayments, FWA increases the administrative burden associated with auditing, investigating, appealing and recovering paid claims. When inaccurate or inappropriate claims are identified before adjudication, plans can avoid pay-and-chase recovery, improve payment integrity, and reduce unnecessary provider abrasion.

Dental FWA claim patterns

Waste and abuse can take many different forms in dental billing and claims submission, and many of them can be addressed through stronger claim editing and expert review. Overtreatment, upcoding, repetitive add-on procedures, and suspect billing patterns can all undermine payment accuracy, trust, and patient well-being. Below are examples of FWA-related issues that advanced dental claim editing may help identify for deeper review:

⒈ Add-on codes for crown procedures, which are categorized as abuse or fraud if the procedure was not performed.

⒉ Upcoding, such as billing for a higher extraction code than warranted.

⒊ Overtreatment, such as performing unnecessary fillings. This can be especially damaging for patients’ teeth, considering that putting a crown on a healthy tooth will naturally weaken it and shorten its longevity. Periodontal procedures such as root planing and scaling are another common example of overtreatment.

⒋ Billing under different providers’ names within a multi-dentist practice in an attempt to sneak FWA past the dental claim system and claim editors.

An effective approach to dental payment integrity

While many dental plans already rely on a primary editor to catch duplicates or simple coding conflicts, advanced dental claim editing provide a critical next layer of protection. A second-pass prepayment review can evaluate claims against national and proprietary edits, clinical guidelines, member history, and plan-specific rules to identify suspect billing that may signal waste, abuse, or potential fraud—without overwhelming internal staff. This deeper level of review helps plans intervene earlier, before inappropriate claims are paid. For example, a national dental payer realized over $64 million in annual savings and a 3% incremental savings rate through Cotiviti’s enhanced dental claim review in a single year.

When suspect claims are flagged and validated before payment, plans can prevent incorrect reimbursement rather than pursuing recovery after the fact. This helps avoid the cost and friction of pay-and-chase while improving financial accuracy upfront. And when patterns suggest broader provider behavior concerns, postpay review and investigation can still play an important role in determining next steps, including provider outreach, education, or escalation in more serious cases. Cotiviti’s dental prepay and postpay solutions can inform each other by suggesting provider enhanced review and identifying new, emerging schemes.

Dental claim editing is further strengthened by professional review of documentation, x-rays and treatment history when needed to validate whether billing services are clinically appropriate and supported by plan guidelines. Applying advanced clinical and coding algorithms to suspect claims help plans distinguish between routine billing variation and issues that warrant intervention, creating a more precise and defensible approach to combating FWA.

Detecting and stopping FWA through more precise dental claim editing and review helps dental plans reduce losses, protect member benefits, and discourage both inappropriate billing and treatment. With the right payment integrity strategy, plans can strengthen oversight, improve claim accuracy, and create better outcomes for payers, providers and members alike.

October 5, 2026
Trump’s ACA Fraud Crackdown: Experts Urge Going After Bad Actors, Not Patients

Addressing fraud, waste and abuse in healthcare has been a major focus of the Trump Administration, particularly with the creation of the White House Task Force to Eliminate Fraud. Last week, the task force took a rather aggressive tactic, announcing that it will cancel 315,000 unauthorized enrollments covering more than 760,000 individuals in the Marketplace. The move, however, is being criticized by many in the medical industry.

The administration anticipates that this will return about $2.2 billion in taxpayer-funded subsidies.

“We are shutting down unauthorized Marketplace enrollments and returning approximately $2.2 billion in taxpayer-funded subsidies,” said HHS Secretary Robert F. Kennedy, Jr., in a statement. “CMS is strengthening safeguards, pursuing bad actors, and holding agents and brokers accountable when they break the rules. Under President Trump, HHS will protect Americans’ health coverage and ensure taxpayer dollars reach the people they are intended to serve.”

One healthcare expert argued that while there’s a need to address fraud in the Marketplace, patients shouldn’t be the ones punished.

“I agree we have to be going after bad actors, but we can’t be going after the patients,” said Dr. Adam Brown, an emergency physician and founder of ABIG Health.

Brown emphasized that these efforts can’t be looked at in isolation. The enhanced ACA premium tax credits expired at the end of 2025, increasing premiums for many Marketplace enrollees. In addition, the Trump administration is implementing Medicaid work requirements that states generally must begin by 2027.

“If you look at these things in isolation, you have a tendency to anchor to, ‘Well, that’s not a lot of people,’ or ‘I’m sure a lot of those individuals that are within that 760,000 number are not real individuals,’” Brown said. “But that all said, when you kind of look at all of these pieces of the puzzle, it makes me question: Are we trying to dismantle some of the important social service safety net type of programs in the country that so many people depend on, without a very clear alternative right now that’s affordable that gives them the necessary access?”

Brown urged CMS to establish a formal process for reinstating people who were wrongly disenrolled. He also called on Congress to extend the ACA tax credits.

Families USA, a patient advocacy organization, also spoke out against the decision.

“Once again, the Trump administration is using alleged fraud accusations as a political smokescreen to double down on what they are actually doing: taking health coverage away from hundreds of thousands of people,” said Anthony Wright, executive director of Families USA. “Real fraud should be stopped, especially dishonest brokers who sign people up without their knowledge. Previously, anti-fraud policies and procedures banned those brokers, but this administration reinstated them. Now families, not bad actors, are paying the price.”

This comes as recent research from the National Bureau of Economic Research found that the broader implementation of the ACA was associated with an estimated 20% to 30% reduction in mortality among people who were uninsured before the law.

With the administration’s decision to remove 760,000 people from ACA coverage, it’s important to note that not all of those people will become uninsured, noted one of the paper’s authors, Robert Kaestner, research associate at the University of Chicago.

“The majority of them are going to have access to other types of health insurance… So 250,000 people who might end up uninsured out of a country of 333 million — that’s not a big change, but still, it’s 250,000 people potentially without health insurance. That’s a very serious consequence,” Kaestner estimated.

Photo: illustration, Getty Images

October 4, 2026