April has seen a slew of executive hires, promotions and layoffs across the healthcare industry. For instance, Aledade, Humana and Zimmer Biomet named new executives. There were also layoffs at organizations including Baylor Scott & White Health Plan, Novo Nordisk and UnityPoint Health.

The post Healthcare Moves: A Monthly Summary of Hires, Exits and Layoffs appeared first on MedCity News.

Tennessee lawmakers recently passed a bill banning PBMs from owning pharmacies in the state, though like a similar Arkansas law, it is expected to face legal challenges if enacted.

The post Will Tennessee’s PBM Bill Face the Same Fate as Arkansas’ Law? appeared first on MedCity News.

Financial assistance is moving from discretionary policy to regulated infrastructure. For health systems, that shift has significant operational and financial implications.

The post Financial Assistance Reform Is Reshaping Revenue Cycle Strategy appeared first on MedCity News.

Lawmakers introduced the Medicare Advantage Improvement Act of 2026 to tighten prior authorization rules, boost transparency and curb practices that delay care.

The post Bipartisan Bill Seeks to Strengthen Oversight of Medicare Advantage appeared first on MedCity News.

Many health plans are discovering that even after digitizing medical policies and implementing FHIR APIs, prior authorization turnaround times remain slow and provider frustration remains high. The reason is straightforward: digitization alone does not make medical‑necessity determinations executable by automated systems at scale.

The post Digitizing Medical Policy Alone Will Not Automate Prior Authorization at Scale appeared first on MedCity News.

Ed Park is sincere and passionate about his calling as the CEO of Devoted Health, which provides Medicare Advantage plans to seniors in 29 states. But it remains to be seen if he can do more or the same with less.

The post CEO of For-Profit MA Plan Tells CMS “Pay Us Less” appeared first on MedCity News.

Since its inception, AI in prior auth has only been at work in the commercial healthcare marketplace. Now new innovative approaches that reframe prior auth as a resource instead of a roadblock have come to Medicare via the WISeR model.

The post ‘Prior Authorization’ Has Become a Dirty Word in Healthcare, But it Might Be Medicare’s Smartest Path Forward appeared first on MedCity News.

Amperos Health’s Series A round was led by Bessemer Venture Partners, with participation from Uncork Capital and Neo.

The post Startup Helping Providers Manage Denied Claims Raises $16M appeared first on MedCity News.

SCAN Health Plan CEO Sachin Jain urged brokers to abandon for-profit plans that treat them poorly, but one broker argued they often can’t because dominant players like UnitedHealth Group control so much of the healthcare system.

The post SCAN CEO Urges Brokers to Drop Plans That Treat Them Poorly — One Says She Has No Choice appeared first on MedCity News.

[Sponsored] In this episode, MedCity News’ Arundhati Parmar chats with a pharmacy benefits leader and a virtual pharmacy operator about ways to modernize and scale prior authorization.

The post MedCity Pivot Podcast: Modernizing Prior Auth appeared first on MedCity News.

Healthcare has solved for the hard part. The science, the surgery, the diagnosis: by global standards, we’re exceptional.
What we haven’t solved for is what happens when the patient goes home.

The post The Healthcare Industry Has a Last Mile Problem — It Hasn’t Realized It Yet appeared first on MedCity News.

At the Medicarians Conference, Ricardo Carcas, assistant special agent in charge of the Office of Investigations, discussed cases of fraud in the ACA and how the DOJ is combatting it.

The post How the DOJ Is Tackling Fraud in the ACA Marketplace appeared first on MedCity News.

Oscar Health launched Lucie, a marketplace aimed at making healthcare more shoppable.

The post Oscar Health Seeks to Build ‘Airbnb for Healthcare’ with New Marketplace, CEO Says appeared first on MedCity News.

By using AI-powered intelligence to shift clinical and coding validation earlier in the healthcare continuum, and unlocking upstream clinical data to inform downstream payment workflows, organizations can proactively prevent errors, reduce downstream churn and friction, and support more predictable, accurate, and timely payments. 

The post The Next Era of Payment Integrity: Earlier Clinical Validation, True Transparency appeared first on MedCity News.

A consultant who has analyzed healthcare policy over many decades declares that MA is in the middle of a fundamental reset both in terms of market headwinds and federal scrutiny.

The post Policy Expert Believes CMS is Taking “Adversial Posture” to Medicare Advantage appeared first on MedCity News.

UnitedHealthcare is exempting rural providers from most prior authorization requirements.

The post UnitedHealthcare Expands Rural Healthcare Initiatives, Reduces Prior Auth Requirements appeared first on MedCity News.

CMS is proposing to make its joint replacement bundled payment model mandatory nationwide. Experts say it is a logical step, but warn that mandatory participation could be challenging for hospitals to implement.

The post Expanding the CJR Model Is a Logical Step in VBC, but Implementation Challenges Remain appeared first on MedCity News.

Rep. Greg Murphy introduced a bill that would require out-of-pocket prescription drug spending to count toward patients’ deductibles and out-of-pocket maximums regardless of where the drugs are purchased.

The post New Bill Seeks to Lower Out-of-Pocket Drug Costs appeared first on MedCity News.

New research from the Elevance Health Public Policy Institute finds that higher enrollment in Medicare Advantage may be linked to lower overall Medicare spending.

The post Report: Growth in MA Is Associated With Lower Total Medicare Spending appeared first on MedCity News.

The Department of Justice has sued both OhioHealth and NewYork-Presbyterian Hospital this year, alleging that they use contracting tactics that limit competition and keep healthcare prices high. The cases mark a broader push by regulators to scrutinize how health systems use “all-or-nothing” contracts to shape insurance networks and patient access.

The post Inside The DOJ’s Hospital Contracting Crackdown: What Message Are the Feds Sending? appeared first on MedCity News.

With data from open enrollment now coming in, we no longer need to rely on guesswork. Let’s take stock of where the ACA Marketplace stands today and what it means for our healthcare system.

The post ACA Stress Test: Four Key Takeaways from This Year’s Open Enrollment appeared first on MedCity News.

Chapter’s Series E round was led by Generation Investment Management, with participation from Fifth Down Capital, 8VC, Stripes, XYZ Venture Capital, Addition, Narya Capital, Susa Ventures and Maverick Ventures.

The post With $100M Raise, Chapter Targets Medicare Mismatches for Seniors appeared first on MedCity News.

The good news: fixing our ancient administrative infrastructure does not require technology that’s particularly experimental, nor does it require passing new laws or regulations. It does, however, require coordination.

The post Healthcare’s Most Fixable Cost Problem: Administrative Waste appeared first on MedCity News.

Cigna Healthcare ranks highest in digital experience among commercial plans, while UPMC Health Plan ranks highest among Medicare Advantage plans, according to a new JD Power report.

The post Which Health Plans Rank Highest In Digital Experience? appeared first on MedCity News.

This is not a debate about care models or physician preferences. It is a contest over who will control the referral pathways and the revenue streams that originate at the front door of healthcare.

The post The Quiet Battle for the Front Door of Healthcare appeared first on MedCity News.

Health insurers have reduced prior authorizations by 11% and are continuing reforms to streamline and speed up approvals, according to an announcement from AHIP and Blue Cross Blue Shield Association.

The post Insurers have Cut Prior Auth by 11% Following Commitments appeared first on MedCity News.

Jefferson Health in Philadelphia is suing Aetna over a new Medicare Advantage payment policy that hospitals say unfairly reduces reimbursements for legitimate inpatient stays. The case highlights a broader clash between providers and Medicare Advantage plans over “downcoding” short hospital stays and controlling costs.

The post Jefferson Health Sues Aetna As Providers’ Frustration with MA Grows appeared first on MedCity News.

“We spend a lot of time focused on building the experiences that we think are the future of healthcare, and we don’t spend a heck of a lot of time worrying about what other people are doing,” declares Dan Caron, founder and CEO of Health Universe. Here’s a Q&A with the leader of the Kleiner Perkins-backed company.

The post CEO Building AI’s “Health Universe” Utterly Unperturbed By Rivals appeared first on MedCity News.

Yuzu’s $35 million round was led by General Catalyst and Chemistry, with participation from Anthropic’s Anthology Fund, Bain Future Back Ventures, Timeless Ventures, Lachy Groom and Neo.

The post TPA Yuzu Health Aims to Revamp Health Benefits with $35M Boost appeared first on MedCity News.

Over the past 15 years, financial and administrative barriers – most notably step therapy mandates and prior authorization requirements – have repeatedly forced patients through suboptimal or ineffective treatments before they can try another therapy, have tied the hands of healthcare professionals and patients alike. Now there’s a possible solution.

The post Join the Fight Against Chronic Pain: It’s Time for Breakthrough Legislation in Congress appeared first on MedCity News.