Healthcare Brew covers pharmaceutical developments, health startups, the latest tech, and how it impacts hospitals and providers to keep administrators and providers informed.

Healthcare Brew

Will Peischel

Healthcare Brew delivers the latest news and trends in healthcare.

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Coffee cup paired with a clock striking midnight

How the two-midnight rule influences Medicare coverage

A whole lot goes into whether a physician admits a beneficiary.

Quinn Sental

The US government opens probe into Change cyberattack

Among its goals, the Department of Health aims to ascertain if “protected health information” was breached.

Shannon Young

Biden admin: Short-term health plans must be ‘truly short-term’

New federal rules will restrict short-term health insurance policies to months, not years.

Dollar bill icon denoting healthcare payers

Payers

Cassie McGrath

Each week, we schedule our rounds with Healthcare Brew readers. Want to be featured in an upcoming edition?

Chuck Lehn has been the president of Banner Plans and Networks since the Phoenix, Arizona-based health system Banner Health launched the insurance company back in 2011.

In fact, he’s been with the nonprofit health system since 1986, originally working on the hospital financial side of the business. Then, after the 

 passed in 2010, Banner execs decided to form their own health plan, which has grown to offer Medicare, Medicare Advantage, and Medicaid (including a joint venture with Aetna) options for the 3.5 million patients the system serves annually.

And while it isn’t uncommon for health systems to own health plans, it certainly makes for different work than running just the plan alone.

Lehn spoke with Healthcare Brew about what it’s like to operate a health plan connected to the Banner system and about the future of health insurance with new technology in play.

“The most important thing that we’re trying to do is change the narrative to: How do we get rewarded for keeping people healthy?” he told us.

This interview has been edited for clarity and length.

Main tasks would be a couple of things: One is paying a lot of attention to our members. How do we make sure that we’re delivering services that are useful? We get feedback through formal and informal call centers and survey data, and measure retention.

Second, we’re paying attention to our regulators. On the external side, it’s a little more governmental, with departments of insurance, Medicare, Medicaid, etc.

Then we’re really focused on our provider network. How do we keep them engaged? Doctors always see the value in helping a patient. And when they see they’re doing more than helping just the patient that’s right in front of them, it’s rewarding for them.

Have any recent policy changes affected your work?

A lot of our business goes as the government goes. In the Medicare space, 

 have been launched. How we can reduce fraud, waste, and abuse has been important.

On the Medicare Advantage side, the big change has been how 

, how risk adjustments are measured. Being able to manage that has been pretty challenging, but we’re weathering that.

Then, a really big change has been with Medicaid. During the Covid-19 pandemic, we had to work so hard to just make sure people had access, and we stood up all 

. Coming out of that, there was a lot of pent-up demand. How do we still get people into the right care with the right provider, in the right setting, etc.? Now, a lot of people are losing coverage 

. How do we keep as many people covered as we can, but be compliant?

How do you see the future of AI or other technologies 

The promise in AI is eliminating a lot of the lower-value tasks and freeing up teams to focus on higher-value work.

The consumer and provider backlash against prior authorization is geared around the administrative hassle of gathering information, submitting it, and then waiting. We have 

 (EMR), we have lots of automation that we’re implementing, so hopefully that heavy work of gathering all of that information and putting it together is automated. It also speeds up decision-making—which is what consumers are looking for—and it lowers cost footprint.

 to help provide better information, and we’re using AI to identify things that could be a problem. If we’re seeing that somebody is scheduling something with a provider that’s not contracted, maybe we could redirect them so that they wouldn’t get a surprise bill.

How does it compare to run a health plan connected to a system versus one that isn’t?

One is that your access to information improves. You’ve probably got direct access to the provider’s EMR, you’ve got access to scheduling—all sorts of administrative things that you typically wouldn’t have. Hopefully we’re using that information on the member’s behalf.

Two, there’s a real opportunity for coordination of care. If the building says “Banner” on it, [providers there are] going to know something about you, going to be able to help you, and hopefully your care isn’t going to have to start all over again.

There’s also really practical things that happen, like when we do outreach to help people get their preventative care completed. They’re more likely to answer the phone if it says Banner Health [is calling].

A portrait of Chuck Lehn, president of the Banner Health Plans and Networks

President of Banner Plans talks running insurance at a hospital 

AI is already making an impact on health insurance, expert says. 

illustrated headshot of caroline catherman, healthcare brew reporter

Caroline Catherman

Normally, you want more customers, right? Apparently not if you’re a health insurance company and those customers come with high medical costs.

With enrollment now underway for next year’s Medicare Advantage (MA) and Affordable Care Act (ACA) marketplace plans, major payers are spiking prices and reducing benefits—an approach they hope strategically 

, according to those companies’ Q3 earnings calls.

Annual enrollment for MA began Oct. 15. The average beneficiary has 32 MA prescription drug plans available in 2026, fewer than this year (34) but higher than the majority of years the program has been around, 

Payers like UnitedHealth and Humana look to be very invested in reducing and shifting MA enrollment.

, Humana President and CEO Jim Rechtin said in an Oct. 2 update the payer wouldn’t be “actively selling” most plans in its largest MA contract, which currently has 3.5 stars. Instead, it’s trying to shift its MA members into plans with four or more stars.

UnitedHealth, too, is backing away from MA. The company had 

 in April after taking on new MA members with higher-than-expected medical costs. The rest of the year has been about coming back from that.

 and is on track to lose 1 million of its 8.4 million MA members in 2026, UnitedHealthcare CEO Tim Noel said in the company’s Oct. 28 earnings call.

Meanwhile, Humana—which had previously projected losing 500,000 members—said in its Q3 earnings it now only expects to lose about 425,000 of its 5.2 million individual MA members due to better-than-expected sales. Alongside this announcement, Humana cut its full-year earnings guidance.

“We are prepared to take targeted actions to slow new sales if we reach the point where the volume risks negatively impacting member experience,” Rechtin said during the company’s Nov. 5 earnings call.

UnitedHealth is also walking back last year’s choice to 

The company raised its marketplace plan premiums by an average 25% and made “targeted service reductions,” which is expected to reduce enrollment by about two-thirds, Noel said during Q3 earnings calls.

Centene EVP and CFO Drew Asher said the managed care provider’s marketplace plans would see an average “mid-30%” rate increase.

Overall, insurers raised marketplace premiums for 2026 

, KFF found, in anticipation of the planned expiration of 

 drags on, it’s still not clear whether they may be extended.

“If the subsidies are extended, we will work closely with states to support implementation and ensure continued access for consumers who rely on this coverage,” Gail Boudreaux, Elevance president and CEO, said during the insurer’s Oct. 21 call.

Payers also continued to gripe that state Medicaid reimbursement rates don’t reflect the acuity of the Medicaid member pool as medical costs rise.

During Elevance’s earnings call, CFO and EVP Mark Kaye pointed to state reverification processes and stricter eligibility requirements as leading to “lower-acuity” members getting disenrolled. Those left behind are sicker and more costly, he said, and rates haven’t caught up, adding that “2026 is going to reflect those same continued pressures in Medicaid as rates catch up to acuity.”

Centene CEO Sarah London said in the company’s Oct. 29 earnings call that the managed care organization is focused on reducing elevated Medicaid costs. Those high costs were one of the factors that led it to 

 its full-year guidance in July, alongside a prediction from actuarial firm Wakely that ACA marketplace enrollees would be fewer and sicker.

Financial services firm Baird analysts noted Centene’s Medicaid business performed “better than expected” in Q3 but it’s too soon to say it’s out of the woods.

“The broader [Medicaid] market is experiencing elevated (if not worsening) cost trends and ongoing membership attrition,” the analysts noted in an Oct. 29 note on Centene’s earnings.

Red down zigzag arrow forming a percentage sign in a yellow background. Illustration of the concept of interest rate fall

Payers continue to predict Medicare Advantage, ACA marketplace enrollment losses

Insurers’ Q3 earnings emphasized margin recovery over growth.

Wouldn’t it be nice if every patient could walk into a hospital and know exactly how much they’ll need to pay? It sure would. But we’re not there yet.

Price transparency legislation took effect for hospitals and health plans in 

 and 2022, respectively, requiring them to publish previously proprietary negotiated rates for all medical services in clear, machine-readable files.

Audits have found many hospitals’ public files 

 from Turquoise Health—a platform that aggregates and analyzes public pricing data from payers and hospitals—found payer files aren’t comprehensive, either.

“They’re reporting on so many entities and so many contracts, and there is a lot of complexity. If anything, it’s a little bit of an indictment into just how complicated the reimbursement landscape is,” Leland Robbins, Turquoise’s senior director of data product, said in an Oct. 27 press briefing.

A little confused, but they’ve got the spirit.

 The biggest issue, the report says, is that many payers list multiple rates for the same procedure, with no way to distinguish between them.

Of 97 payers analyzed, 28 gave “conflicting” rates for the majority of services. CVS subsidiary Aetna, for instance, did so for 57% of its listed services.

Aetna seemed to be the biggest offender among major insurers, compared to UnitedHealthcare (6%), Cigna (6%), and Anthem (16%).

CVS declined Healthcare Brew’s request for comment. But Robbins said during the briefing the company has been in touch with Aetna about its score, and the payer is working toward fixing this.

“I don’t think this is a case of them doing something purposefully to make it confusing,” Robbins said.

The report also checked payers’ machine-readable files for outliers, meaning obvious errors where something is clearly listed at the wrong price, like an organ transplant listed for a penny. Turquoise also tracked how many files it could successfully ingest, or parse, per payer per month, a metric that points to whether payers are making their files accessible.

These issues were rarer: Only about 10% of payers were flagged for having too many outlier prices and less than 10% were flagged for not being parsable.

It’s important to ensure payer data is accurate because “insurers, not providers, create the algorithms that convert negotiated rates for services into actual prices that patients and employers pay,” Ariel Levin, the American Hospital Association’s director of coverage policy, told Healthcare Brew via email.

Turquoise Health Chief of Staff Carol Skenes hopes these data analyses can be a tool in the future for patients, payers, hospitals, and policymakers alike to make sense of the complex world of healthcare rates, she said during the briefing. The company has a product that incorporates both hospital and payer data plus reference data from other claims, Medicare, and Medicaid.

“There are a lot of gaps in the hospital files. There are a lot of gaps in the payer files. When you start to bring these things together…you can actually start to get a pretty good signal here of what the real truth is,” Robbins said.

In February, President Trump called for a makeover of price transparency efforts, accusing the rules of being “slow walked” by the last administration. Then in May, the federal government announced that technical requirements for payers’ machine-readable files were being updated, with the update finalized Oct. 1 and required starting Feb. 2, 2026.

Hospital cross symbol with money coming out of it.

Health plan price transparency still needs work, report finds

To be totally transparent: We still don’t know how much a procedure costs.

One word defined Medicare Advantage (MA) star ratings this year: stability.

The Centers for Medicare and Medicaid Services (CMS) publicly released much-anticipated 2026 

 on Oct. 9. These ratings, ranked from one to five,

determine the distribution of billions of dollars in quality bonus payments from CMS for plans ranking four or higher.

Over the last few years, the weighted proportion of members in plans with four or more stars has jumped around dramatically from 79.5% in 2024 to 64.1% in 2025, according to an analysis from consulting firm 

. But for 2026, the proportion stayed pretty stable at 63.5% by HealthScape’s calculations.

“In some ways, stability is a good thing, especially given how volatile the Medicare market is these days. But the flip side of that is we didn’t really see meaningful improvement,” Alexis Levy, senior partner at HealthScape Advisors, told Healthcare Brew.

Plans have had a rough few years. Their 2024 star ratings were lower than anticipated after CMS adopted a new methodology to calculate star cutoffs, prompting insurer 

 against CMS for how it calculated its scores.

 its 2024 ratings, translating to about $1 billion more in bonus payments, according to healthcare analytics firm Cotiviti.

Plans took issue with the 2025 ratings as well, though. 

 sued CMS over how it calculated its call center measure, which looks at factors like average hold times and disconnect rates. (UnitedHealthcare and Centene 

 Stability isn’t good news for everyone, however.

 benefited. UnitedHealthcare Group, Elevance, and 

 saw their estimated members in plans with four or more stars increase for 2026, with Centene seeing the largest jump from 1% of its members in plans that met that threshold to 19.8%, according to healthcare consultancy Wakely’s October 

The Kaiser Foundation Health Plan maintained nearly 100% of its members in four-star or higher-ranking plans.

But Humana, the second largest MA insurer with 5.8 million members, isn’t doing so great.

 of the top 15 insurers in 2025, according to a 2024 HealthScape analysis. According to an October 2024 8-K filing, enrollment in plans of four or more stars fell from 94% for 2024 to 25% for 2025.

For 2026, the proportion of members in plans four stars and above went down even further, to 20%.

Humana said in an Oct. 2 form 8-K filing it’s “not satisfied” with its 2026 ratings but has already made 

 that should allow it to get back on top for 2027.

The payer will not be “actively selling” most plans in its largest MA contract—which currently has 3.5 stars—and will instead steer new customers toward four- and 4.5-star plans while also focusing on improving other measures that determine star ratings, like member engagement and the call center experience, Humana CEO and President Jim Rechtin said in an update posted Oct. 2.

Based on these ratings, Wakely’s analysis predicts “approximately the same” quality bonus payments in 2027 as in 2026.

In 2025, CMS will dole out $12.7+ billion, according to an estimate from 

. These payments are meant to be reinvested to benefit plan members, though some researchers say there’s 

Levy thinks this year could lend itself to less legal drama, at least.

“There weren’t as many huge programmatic changes to the measure calculations that a lot of the plans were suing over in the previous years,” Levy said.

Stability returns to Medicare Advantage star ratings

No news is good news, apparently.

UnitedHealth Group, Cigna, and Humana all have something in common—besides being major health plans, that is.

They’re all currently facing lawsuits from patients alleging AI programs led to denied care. These suits claim (pun not intended) the insurance companies used AI-based algorithms to deny care without human oversight.

 of healthcare by leaders across the industry. AI scribes have 

 to give clinicians more face time with patients and better work-life balance, while also saving hospitals money. 

, able to carry out complex tasks autonomously, have turbocharged the tech’s potential.

 these tools are being adopted faster than safeguards, despite concerns about 

. Now, with all the emerging lawsuits, the outlook of AI in healthcare is looking even more complicated.

Fawad Butt, former chief data officer of Kaiser Permanente, UnitedHealthcare, and Optum, told Healthcare Brew there’s been a lack of oversight regarding “whether algorithms are behaving as good actors or bad actors.”

UnitedHealth spokesperson Eric Hausman told us it isn’t used for “adverse coverage decisions,” Cigna spokesperson Justine Sessions told Healthcare Brew AI isn’t being used to deny claims, and Humana didn’t respond to a request for comment.

But providers say the opposite—that plans 

 using AI for denials. While bigger health systems have more resources to appeal denials, some experts say independent rural hospitals

could be hit harder. A 2023 Stat investigation 

 UnitedHealth was using predictive algorithms to decide when some patients should be cut off from care.

Alexa McKinley Abel, director of government affairs and policy at the National Rural Health Association, said the research and advocacy organization is hearing rural hospitals are increasingly burdened by responding to prior authorization and claims denials because they have 

“If plans’ use of AI means even more prior authorization denials, then we would have concerns about the increasing paperwork and time associated with rectifying the denials for hospital staff as well as delays for rural patients that need to receive care,” she said.

The Centers for Medicare and Medicaid Services doesn’t require insurance companies to share how prior authorization decisions are made or how predictive technology is used in the process, so most of the evidence comes from providers, patients, or insurers that choose to self-report.

 from the National Association of Insurance Commissioners found 84% of 93 insurers used AI, with 50% saying they use it or are exploring its use to detect fraudulent claims, 68% for prior authorization approvals, 61% for disease management programs, and 45% for sales and marketing.

Only 9 of the 93 (12%) said they used or were considering using it to deny prior authorization requests.

Infinitus is an agentic communication platform that currently works with providers such as Medicare Advantage company Zing Health and Gramercy Surgery Center. The voice agent software can do things like conduct health risk assessments and handle specialty pharmacy prior authorization approvals for plans.

“The direction of travel for the industry is to introduce things that we fundamentally couldn’t do today because of a lack of human capital,” Infinitus CEO and founder Ankit Jain said.

On the other hand, healthcare providers and patients are using AI, too, for tasks like appealing denials. Startups 

 are an example of this, creating tools that collect patient and coverage information, then format and send a letter to the plan.

But insurers say some providers are taking AI too far.

Elevance CEO Gail Boudreaux alleged in a July earnings call “isolated pockets” of hospitals are using AI to “increase documented acuity,” driving up unit costs for the insurer. And Centene CEO Sarah London said in her company’s July earnings call that the insurer uses AI in response to that trend.

“As [hospitals] integrate AI into the revenue cycle, we’re integrating AI into payment integrity to make sure that we are sort of keeping pace with all of that,” London said.

Marc Douek, managing partner and co-owner at physiotherapy chain Renew Wellness, told us the chain cuts hours of work down to minutes by using a tool called Spry to automate prior authorization requests and appeals.

A 2024 American Medical Association survey found physicians and their staff spend an average of 13 hours a week completing prior authorization requests. It’s also an expensive process, as the healthcare industry 

 on prior authorization in 2023, according to the 2024 CAQH Index Report.

“Without using Spry in the automation…we wouldn’t be able to expand. We wouldn’t be able to treat our patients. We’d have to just turn people away,” Douek said.

Based on his conversations with insurers, Butt said providers have adopted AI faster—and insurers, which “haven’t adopted agentic [AI] as quickly,” now feel the tech has them “under the gun.”

“They’re left with old technology and humans responding to this deluge of appeals that are coming in from providers who just bought a software or an agent that essentially keeps appealing everything,” he said.

Butt is also co-founder of startup Penguin Ai, a platform intended to be a one-stop shop where both payers and providers can create AI agents. He believes both will need them in the future.

“What I predict is that it’s going to be agent wars galore,” he said.

Virtual Digital hand of Artificial Intelligence (AI). Healthcare technology and innovation concept. Hologram. 3d rendering

The AI arms race between insurers, providers has begun

Health plans have already been accused of using AI to deny patients. 

As people across the country consider their 2026 health insurance options, there’s a massive elephant in the room: Some aren’t thrilled with the industry right now.

, global research and advisory firm Forrester found only 54% of 12,036 insurance customers describe health insurers as trustworthy.

 of consumers were satisfied with their coverage, that is the past.

Forrester found waning trust may impact business. Survey results included in the report show that of 7,512 customers, those with less trust in their insurer were 10.3x more likely to switch insurers compared to high-trust customers, up from 2.4x more likely in 2024.

“As consumer choices expand, including not buying health insurance, the risk of churn becomes more pronounced,” Forrester Principal Analyst Arielle Trzcinski told Healthcare Brew.

Over the last few years, allegations of health insurers’ wrongdoings have come to the forefront, Katherine Hempstead, senior policy advisor for nonprofit the Robert Wood Johnson Foundation, told us.

 that found UnitedHealthcare had pressured clinicians to follow algorithms that cut off certain patient care. 

“That kind of reporting has left a really bad taste in peoples’ mouths and confirmed a lot of suspicions,” Hempstead said. “[Insurers] have to do a lot of work to undo that damage.”

Since then, many health insurers have talked the talk in an effort to bridge the divide. In June, UnitedHealth and other major health insurers 

, which 93% of physicians say delays patient care, according to a 2024 American Medical Association survey.

, however, found 6 in 10 adults feel it’s “not too likely” or “not at all likely” health insurance companies will follow through.

Trzcinski said she’s talked to some insurers who are walking the walk, too.

Other survey results in the report show that, of 562 adults, only 53% felt they understood claim decisions. Trzcinski said Forrester client 

 is an example of a company “overhauling” the explanation of benefits to include more straightforward language.

Trzcinski also pointed to Blue Shield of California, which has committed to answering “at least 80% of prior authorization requests in near real time” in 2027. Prior authorization “typically” takes 24 to 72 hours, according to a page on the insurer’s website last updated in October. (Specific data on this is not required to be published and thus hard to track.)

“Health insurers must put in the hard work to repair trust and their brand image. Rebuilding trust and improving brand experience is much more than just a marketing campaign or a messaging problem,” Trzcinski said.

Illustration of a business man getting rained on by downward arrows.

Trust in health insurers ‘nearing the point of no return,’ survey finds

You can’t trust anyone these days, apparently.

As of 12:01 Wednesday morning, the US government has shut down.

The shutdown, the first since 2018, came about because congressional Democrats and Republicans 

 on a spending bill. A key line in the sand: Democratic leaders want to 

 2021 enhanced Affordable Care Act (ACA) premium subsidies while Republican leaders want to allow them to expire at the end of the year.

If they expire, premiums are expected to spike for the 24+ million people enrolled in the 

, and providers are expected to lose billions in revenue, per a recent 

 from nonprofit Robert Wood Johnson Foundation.

In the meantime, as Congress dukes it out, healthcare is going to look a little different.

For one, without a spending plan, several pandemic-era Medicare flexibilities are no longer in effect.

A 2020 waiver allowing hospitals to deliver inpatient care to Medicare patients 

As of July 2025, 400 hospitals across 142 systems and 39 states were approved to provide hospital-at-home services, according to a July American Hospital Association (AHA) fact sheet.

The Centers for Medicare and Medicaid Services (CMS) ordered all hospitals with active waivers to 

their hospital-at-home patients or return them to the hospital on Sept. 30, according to an alert on the agency’s page.

This pause may “hamper long-term progress for the hospital-at-home program,” AHA spokesperson Colin Milligan told Healthcare Brew.

Flexibilities that reimbursed telehealth care for Medicare beneficiaries at their homes regardless of where they lived also expired Oct. 1, despite 

 must take telehealth appointments from locations such as a provider’s office or skilled nursing facility within a rural health professional shortage area, a federal telehealth demonstration project, or in a county that isn’t in a metropolitan statistical area.

Exceptions are made for behavioral health and substance use treatment and for people with some other medical conditions such as kidney failure, according to the Department of Health and Human Services (HHS).

Some providers and hospital systems have reportedly started blocking these patients from scheduling visits, though 

 are still providing telehealth care in the hopes of later retroactive payment, according to an Oct. 1 letter from the American Telemedicine Association’s advocacy arm, ATA Action.