Tuesday, April 7, 2026

CMS declined to finalize guardrails on artificial intelligence use in MA prior authorization decisions. The agency also suspended the Biden-era requirement for MA plans to publish plan-level health equity analyses of denial rates by population (dually eligible, low-income, disabled). The aggregate-only reporting requirement remains — contract-level, not plan-level, with no service-type breakdown.

Ensemble partnered with Cohere to build a custom LLM trained on synthetic RCM data — not prompt-wrapped general models. Zero PHI in training. Model targets end-to-end orchestration from patient intake to account resolution. Release: H2 2026. Ensemble claims standard AI approaches hit accuracy ceilings from long-context inputs and heavy prompt engineering.

CMS penalties went live April 1. $10/bed/day up to $5,500/day for non-compliance. New requirements: hospitals must disclose median allowed amount plus 10th/90th percentile allowed amounts. Must encode organizational NPIs in machine-readable files. 46% of hospitals were non-compliant under old rules. Payers are already using published pricing data to cross-reference claim amounts — outdated or missing MRFs create denial risk.

Enhanced ACA premium tax credits expired December 31, 2025. Average premiums jumped 114% — from $888/year to $1,904/year. 9% of 2025 enrollees are now uninsured. 5M projected to lose coverage entirely (Urban Institute / Commonwealth Fund). 55% of reenrollees cut food and clothing spending to afford premiums. A person making $28,000 went from paying $325/year to $1,562/year.

House committees questioned CEOs of UnitedHealth, CVS/Aetna, Cigna, and Humana on January 22. Rep. Barragan cited UHG CEO Andrew Witty's $60M one-time equity award. Rep. Carter asked CVS CEO David Joyner to justify $41M in 2024 compensation. MA prior authorization denials jumped 56% year-over-year. National Nurses United published research showing higher denial rates correlate with higher CEO pay across all major insurers.