Monday, April 13, 2026

Ballad Health filed suit against UnitedHealth Group for $65 million, alleging UHC denied physician-ordered post-acute care for patients while simultaneously overstating patient illness severity to collect higher Medicare risk-adjustment payments. The lawsuit targets two distinct schemes: wrongful denial of care already prescribed by physicians, and fraudulent upcoding to inflate Medicare payments received by the insurer. Documents in the parallel nH Predict case are due in 16 days.

Washington state's HB736, signed this month, prohibits insurers from issuing a denial based solely on AI review — a licensed clinician must sign off. At least 13 other states are advancing similar legislation. In parallel, CMS launched its WISeR pilot: AI-assisted (not autonomous) prior authorization review in six states (NJ, OH, OK, TX, AZ, WA) running 2026–2031. West Virginia passed prior auth reform after a patient died following repeated algorithmic denials.

Effective April 1: 3.26% Medicare conversion factor increase for most clinicians, 80+ new ICD-10-PCS codes, new short-duration RPM billing codes (2–15 day windows, eliminating the 16-day minimum), and site-neutral payment expansion to off-campus provider-based departments at 40% of OPPS rates. UnitedHealth simultaneously rolled out enhanced Professional/Technical Component policy enforcement on lab and radiology claims — with automated pre-payment denial triggers now active.

Mathew Evins, a marketing executive, spent 7 months fighting his insurer for approval of medically necessary back surgery for an 8-year chronic condition. Initial request denied. Insurer mandated 6 additional weeks of physical therapy. Denied again. Evins eventually hired Sheer Health — a third-party patient advocacy firm — to manage the appeal, which was ultimately approved. No dollar figure cited, but the firm's existence (founded specifically to fight insurer denials on behalf of patients) signals a growing market for outsourced denial fighting.

Civica Rx — a nonprofit founded by hospital systems — launched insulin at $55 per box on January 1, 2026 (wholesale: $45 for five pens). Eli Lilly, Sanofi, and Novo Nordisk charge $150–$500 per box for equivalent products. 37 million Americans have diabetes. Civica's launch is the first credible price floor set by a non-manufacturer in the US insulin market.