National News

OIG Audit Finds Millions in MA Overpayments to UHC & Humana

Audits by the U.S. Department of Health and Human Services Office of Inspector General found that the two major Medicare Advantage (MA) insurers received an estimated $177.8 million in improper payments from Medicare after submitting diagnosis codes that were not supported by patients' medical records. The audits are part of a broader...
National News

Molina to Leave MA Market in Three States

Molina Healthcare said on Sept. 18 that it will withdraw completely from the Medicare Advantage market in Connecticut, Mississippi and Nevada in 2027. The insurer is narrowing its focus to dual-eligible special needs plans (D-SNPs). The move goes beyond Molina's February announcement that it would stop offering standard individual...
Arizona News

Ascension to Sell Mercy Care Stake to Aetna

Ascension is selling its ownership stake in Mercy Care to Aetna, shifting full ownership of the Arizona managed-care plan to a company that has administered its day-to-day operations for more than two decades. The transaction, which remains subject to regulatory review and approval, would give Aetna full ownership of Mercy Care. Terms...
News

American College of Physicians Explore Ethical Guardrails for AI in Healthcare

Artificial intelligence is moving deeper into clinical practice, but physicians should use it to augment, not replace, their clinical judgment; according to a new position paper from the American College of Physicians (ACP). The paper, published in Annals of Internal Medicine argues that the rapid adoption of AI requires physicians to...
Arizona News

Medicaid Groups Sue CMS Over Work Requirement Exemption - Again

Stakeholders argue the new policy improperly narrows an exemption for medically frail people from the new Medicaid work requirements. The lawsuit, filed Sept. 18 in the U.S. District Court for the District of Maryland, is the second legal challenge to the Centers for Medicare & Medicaid Services’ (CMS) interim final rule...
Arizona News

SCAN Expands Retail Strategy With Walmart-Branded Medicare Plans

Walmart is making another move into Medicare Advantage, partnering with fast-growing SCAN Health Plan to develop co-branded plans that could link insurance coverage with the retailer’s pharmacy, vision, food and over-the-counter services. The companies said the plans will launch in two states and could be available to more than 2...
Arizona News

New CMS Roadmap to Determine Medicaid Medical-Frailty Exemptions

The Centers for Medicare & Medicaid Services (CMS) provided a new roadmap for deciding which Medicaid beneficiaries are too medically impaired to meet 2027 work requirements. However, they leave much of the clinical and administrative decision-making to states.  Issued Sept. 8, CMS' guidance outlines an optional...
Arizona News

RHTP Brings Opportunity for Rural Arizona as Transparency Issues Emerge

Arizona is set to receive $167 million in the first year of a five-year federal rural health program intended to transform care, but questions are emerging over whether the funding can address the financial pressures facing rural providers as Medicaid cuts take effect. The program is also facing questions about transparency, according...
Available To All

CMS Expands Medicare ACCESS Chronic Care Model

Medicare’s ACCESS chronic-care model will add four new condition tracks next spring, doubling down on its effort to tie payments to patient outcomes rather than volume of care. The Advancing Chronic Care with Effective, Scalable Solutions, or ACCESS, voluntary model is designed to give Medicare beneficiaries more options for managing...
National News

J&J Requires 340B Providers to Submit Claims Data For Drug Discounts

Johnson & Johnson (J&J) is requiring health care providers participating in the federal 340B drug discount program to submit claims data for its medicines, adding new reporting requirements as drugmakers seek greater oversight of the program. This week J&J announced it was requiring providers to submit claims data for each...
The 2026 Medicare Advantage Data Edition Data Resources

The 2026 Medicare Advantage Data Edition

Before the 2027 Annual Enrollment Period (AEP) begins, Arizona healthcare leaders need a clear view of where the Medicare Advantage market has been—and where it appears to be heading. The Hertel Report’s 2026 Arizona Medicare Advantage Data Edition provides that foundation, tracking the enrollment, product and competitive shifts...
Arizona Comings & Goings

Phoenix Children's: New Leadership Announcements

Phoenix Children’s has added two senior executives to lead its nursing workforce and its foundation's operations. Tarra Kerr has been appointed senior vice president and chief nursing officer, overseeing strategy and operations for more than 2,100 nurses at the pediatric health system. Her responsibilities include workforce...
AMA Releases CPT 2027 Code Set National News

AMA Releases CPT 2027 Code Set

The American Medical Association released its 2027 Current Procedural Terminology (CPT) code set, with 453 editorial changes designed to reflect new medical technologies and evolving clinical practices. The update includes 299 new codes, 74 revisions and 80 deletions and takes effect Jan. 1. One of the most significant changes...
CMS: Does Medicare Advantage Really Need All Those Special Needs Plans? Government

CMS: Does Medicare Advantage Really Need All Those Special Needs Plans?

The Centers for Medicare & Medicaid Services (CMS) is considering whether the three types of Medicare Advantage Special Needs Plans (SNPs) should remain separate or be streamlined, a move that could reshape how specialized coverage is offered to some of Medicare’s most vulnerable beneficiaries. Arizona MA SNP plans serve about...
National News

Medicaid ACOs - Improving Prenatal & Postpartum Health

A new study of Massachusetts' Medicaid ACOs offers a potential roadmap for improving maternal health. Set clear expectations, give healthcare organizations the resources to meet them and track patients beyond the traditional boundaries of pregnancy care.  The study, published in The Milbank Quarterly, examined how Massachusetts...
Arizona News

More Than 400,000 Arizonan's Medicaid Coverage at Risk

Arizona is preparing for major changes to its Medicaid program that could affect more than 400,000 adults enrolled through the state's Medicaid expansion. The new rules go beyond work requirements. Beginning in 2027, affected Medicaid recipients will have to renew their eligibility every six months versus annually, creating additional...
Government

CMS Renames ICHRAs as CHOICE Arrangements

CMS renamed ICHRA as CHOICE arrangements last week at an event in Indiana, claiming the model is an alternative to traditional employer-sponsored health insurance.   CMS Administrator Dr. Mehmet Oz pointed to Oscar Health as an example of a company supporting the emerging CHOICE framework, as reported by BenefitsPro.com. He...
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