Monday, June 15, 2026

Aetna will pay $117.7 million to settle False Claims Act allegations that it submitted inaccurate diagnosis codes to inflate Medicare Advantage payments. The settlement, which requires federal court approval, resolves claims that the insurer failed to delete invalid diagnosis codes and submitted unsupported codes for enrollees. This follows similar, larger settlements with other major MA insurers in recent years. For practices, it signals ongoing, aggressive government scrutiny of risk adjustment data. Monitor for potential payer policy tightening around medical record documentation requests and chart reviews, particularly for chronic conditions like diabetes and heart failure, as insurers seek to insulate themselves from future liability.

CMS has issued a proposal to make its Medicare drug price negotiation authority a permanent program. Established by the Inflation Reduction Act, the initiative currently allows CMS to negotiate prices for a limited number of high-cost drugs. The proposal would codify the negotiation framework beyond its initial statutory parameters, signaling a long-term policy commitment. This structural shift away from pure market pricing will influence manufacturer strategies and, eventually, formulary composition for Medicare Part D and potentially commercial plans. While direct impact on practice billing is limited, it reinforces a trend of increasing federal intervention in drug pricing that affects overall plan costs and patient access dynamics.

HHS published a Request for Information seeking public comment on a comprehensive review of the Affordable Care Act's Essential Health Benefits framework and the Typical Employer Plan Standard. The review will evaluate coverage adequacy, scope of services, and the benchmark plan selection process. The agency is soliciting input from states, insurers, providers, and consumers on potential updates or reforms. This is a foundational regulatory exercise that could reshape minimum coverage requirements for individual and small-group health plans starting in 2027. The comment period opens June 15; HHS has not set a deadline for final policy changes. Practices should monitor the docket for proposals affecting covered services, especially in mental health, maternity, and prescription drug categories.

Cigna's pharmacy benefit manager Express Scripts filed a lawsuit challenging a Tennessee law that restricts pharmacy ownership by PBMs and insurers. The state law, designed to protect independent pharmacies from vertical integration by large PBMs, is now facing a legal test that could influence similar legislation in other states. Express Scripts argues the law interferes with interstate commerce and conflicts with federal ERISA provisions. The case highlights the ongoing tension between state regulators seeking to preserve local pharmacy access and national PBM operators consolidating market power. A ruling against the Tennessee law could accelerate PBM consolidation, potentially tightening formularies and narrowing pharmacy networks for providers and patients.

A Washington Post analysis reports that new Affordable Care Act rules expanding insurance plan choices for 2027 may come with increased financial risk for patients. The regulatory changes allow insurers to offer more plan variations with differing cost-sharing structures and provider networks. While the expansion aims to increase consumer options and competition, analysts warn it could lead to plans with higher deductibles, narrower networks, or more restrictive formularies that shift costs onto patients. This shift could impact patient collections and prior authorization patterns for practices, as enrollees may face unexpected out-of-pocket costs even with coverage. The analysis suggests regulators will need stronger consumer protections to prevent adverse selection and ensure network adequacy.