Tuesday, April 14, 2026

On April 10, CMS released a proposed rule (CMS-0062-P) that extends electronic prior authorization requirements to prescription drugs for the first time. Payers would need to respond to urgent drug PA requests within 24 hours and routine requests within 72 hours — matching the timeline already in place for medical services since the 2024 interoperability rule. The rule also requires payers to publish denial metrics for drugs annually and provide specific reasons when denying a drug PA request. Compliance date proposed: October 1, 2027. Comment period closes June 15, 2026.

On March 30, a federal judge in Massachusetts denied motions to dismiss filed by UnitedHealth, Aetna, Cigna, Elevance Health, and Humana in an antitrust case centered on Zelis Healthcare, a payment management vendor. The lawsuit — brought by a coalition of healthcare providers including physician groups, dental practices, and solo practitioners — alleges the insurers conspired with Zelis to systematically suppress out-of-network payments. Zelis earns a percentage of the gap between what providers bill and what is paid. The complaint claims some providers saw their out-of-network revenue cut by more than half. The case now enters discovery.

ACA marketplace insurers denied 19.1% of in-network claims in 2024 — 8.8 million rejected claims out of 46 million submitted. The rate fell from 22.5% in 2023, the largest single-year drop on record, but remains above the 2021 baseline of 16.7%. Fewer than 1% of those 8.8 million denials were appealed. Of the claims that were appealed, insurers upheld their own denials 56% of the time. A separate study found 57% of denied Medicare Advantage claims are overturned when appealed — evidence that most denials are reversible, and that the gap between what's contested and what's recoverable is enormous.

A new PIRG report, Outpatient Outrage 2026, documents the spread of hospital facility fees to outpatient and office-based settings. Beth Davis of Mentor, Ohio, received a cortisone shot at a hospital-owned clinic. The physician's fee was billed separately. The facility fee on her bill: $2,418. She was never observed, never admitted, and never in a bed. Kaitlin Johnson of Minneapolis brought her 8-year-old daughter for 40 allergy tests at an M Health Fairview clinic. Total billed: $24,400. After insurance: $5,400 owed by the family. These fees are legal in 49 states because Congress's 2022 No Surprises Act left facility fees untouched. A House bill passed in February 2026 would close the loophole, but it has not cleared the Senate.

The US spent $14,775 per person on healthcare in 2024, according to OECD data analyzed by the Peterson-KFF Health System Tracker. The peer nation average: $7,393. Switzerland, the second-highest spender, reached $9,800. The US spends at least 40% more than any other country in the world. The gap is not driven by utilization — Americans visit doctors less frequently than most peer nations. It is driven by prices. Administrative overhead alone accounts for $925 per person in the US versus $245 per person in comparable countries — a $680-per-person difference attributable entirely to billing complexity. Despite this spending, US life expectancy ranks below most peer nations.