Friday, April 10, 2026

CMS finalized $13 billion in additional 2027 payments to Medicare Advantage plans and simultaneously abandoned cost-control oversight requirements that had been under development. MA plans receive a net payment increase while facing reduced regulatory scrutiny on prior authorization behavior and denial practices. This follows the March 31 PA data publication — the first time payers had to publish aggregate denial metrics — and effectively rewards plans while pulling back the accountability mechanism.

Federal judge ordered UnitedHealth to hand over all internal nH Predict design records, compensation arrangements for medical directors who approved denials, and government investigation files by April 29. Plaintiffs allege the algorithm overrode physician decisions for elderly rehab patients with a 90% error rate. The court specifically ruled UnitedHealth must disclose whether the technology was designed to override clinical judgment. Between 2019 and 2022, UHC's post-acute denial rate rose from 8.7% to 22.7%. Skilled nursing denials increased ninefold.

The CMS Wasteful and Inappropriate Service Reduction model crossed the 100-day mark April 10. Seventeen procedures now require AI-assisted prior authorization in Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Standard turnaround: 3 days. Urgent: 2 days. Providers who achieve ≥90% affirmation rate qualify for gold-card exemption from future reviews. Commercial payers (BCBS, Aetna, UHC) copied WISeR criteria into their own commercial policies within 90 days of the January 1 launch — expanding the model's effective footprint far beyond the six pilot states. Wound care and orthopedic billing teams are most exposed.

Patients who see doctors at hospital-owned clinics receive a "facility fee" on top of their normal copay — ranging from $25 to thousands of dollars — for annual physicals, strep throat tests, and telehealth appointments. The charge appears because the clinic is owned by a hospital system, not because anything additional happened clinically. New Mexico banned facility fees on telehealth visits March 6 (HB 306). California, Texas, and New York have active bills. Forty-nine states currently allow it with no restriction. Hospital outpatient clinic acquisitions expanded in 2025-2026, spreading the fee to millions of new patients.

With pandemic-era enhanced premium tax credits expired in December 2025, average ACA marketplace premiums rose 26% in 2026. A St. Louis property manager with family coverage now pays $650/month — $200 more than last year for identical coverage. In previous reporting (April 6 pulse): subsidy recipients saw $888→$1,904/month. An estimated 5 million people lost coverage. 55% of reenrollees cut food or clothing spending to stay insured. 2026 bronze plan deductible: $7,186.