Sunday, April 5, 2026

Summary: CMS launched the WISeR (Wasteful and Inappropriate Service Reduction) Model on January 15, 2026 — a 6-year AI-driven prior authorization program for skin substitute applications. Live in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, Washington. BCBS, Aetna, and UnitedHealthcare tightened skin substitute PA criteria within 90 days, applying WISeR-level scrutiny even outside pilot states. Wound care and surgical specialty denials spiking nationally.

Summary: FTC settled with Express Scripts over insulin pricing manipulation. Express Scripts pushed manufacturers to compete on rebate size rather than net price, retained inflated rebates. Expected savings: $7 billion over 10 years in out-of-pocket insulin costs. Caremark and Optum face identical lawsuits. Congress passed H.R. 7148 delinking PBM compensation from drug price in Medicare Part D.

Summary: Three largest MA payers retrenching simultaneously. Humana: 3 fewer states, 194 fewer counties. UnitedHealthcare: 1 fewer state, 109 fewer counties. Aetna: 1 fewer state, 100 fewer counties. OTC benefits cut across all three for non-SNP plans. Spartanburg Regional going out-of-network with Aetna MA effective April 15. 15% of local PPO MA plans canceled for 2026.

Summary: Court filings in the UnitedHealth AI denial case now cite a 90% error rate for the nH Predict algorithm. The system allegedly overrode physician determinations for elderly rehab patients, leading to premature discharges, family savings depletion, and documented deaths. April 29 document deadline stands. Tens of thousands of documents ordered produced.

Summary: New Jersey completed its sixth round of medical debt relief: $86 million eliminated for 53,000 residents. Cumulative program total: $1.4 billion in medical debt for 828,000+ residents. AB 6309 also limits personal information collection by healthcare facilities and government entities to what's needed for service delivery.