Where we’re going

Health insurance claim denials are on the rise, creating new challenges for patients, employers and plan sponsors. Behind many of these denials are layers of administrative complexity—such as prior authorization requirements, coding errors and insurers’ cost-cutting tactics that often block or delay payment for legitimate medical services. In 2023, nearly 20% of claims submitted to … Continued

The latest Healthcare Price Transparency Executive Order reaffirms the federal government’s commitment to ensuring that hospitals and insurers disclose actual healthcare costs rather than vague estimates. This action aims to empower patients and create a more competitive market for consumers using health care services. However, plan sponsors and providers may garner greater value from those … Continued

The role of private equity (PE) in healthcare has expanded rapidly, reshaping financial and operational priorities. From large hospital systems to specialized physician groups and ancillary services, PE firms have been acquiring healthcare organizations at an unprecedented rate. The repercussions from such investments are complex, potentially increasing healthcare costs, reducing the quality of care and … Continued

In a recent ruling, the Fifth Circuit Court supported important aspects of the No Surprises Act (NSA), reinforcing provider protections and clarifying how insurers should determine the Qualified Payment Amount (QPA). This decision not only influences the structure of out-of-network billing disputes but also aims to ensure more transparency and timely payments. Here’s a look … Continued

With the rapid modifications in healthcare legislation, it is essential for plan sponsors and employers to stay informed. Christine Cooper and Jack Towarnicky’s recent BenefitsPRO article provides a comprehensive analysis of how this landmark legislation could reshape the dynamics of employer-sponsored health plans. Understanding the Inflation Reduction Act (IRA) The Inflation Reduction Act (IRA) introduces … Continued

The Hospital Price Transparency Rule mandates that hospitals publicly disclose comprehensive pricing data, including negotiated rates for all services and items. The 2024 Hospital Price Transparency Report paints a concerning picture of noncompliance with federal hospital price transparency rules. Of the 2,000 hospitals reviewed, only 21.1% were found to be fully compliant. The report underscores … Continued

The Kaiser Family Foundation’s (KFF) 2024 Employer Health Benefits Survey offers a comprehensive snapshot of the current state of employer-sponsored healthcare in the U.S. Covering over 154 million nonelderly Americans, employer-sponsored plans are a cornerstone of healthcare delivery. The survey highlights trends such as rising premiums, shifting plan designs and the increasing prevalence of high-deductible … Continued

In this recent Benefits Law Journal article, Jack Towarnicky, aequum member, identifies a number of the statutory requirements designed to improve health care claims processing – changes that were included in Health Reform and subsequent laws. Jack asserts that health reform mandates and bureaucratic solutions may not be the most cost-effective option to achieve the … Continued

Steering though the continuously shifting landscape of healthcare regulation can be daunting, especially when it comes to the Affordable Care Act (ACA). With the ACA’s affordability threshold for employer-sponsored health plans shifting annually, staying compliant is more critical than ever for applicable large employers (ALEs). In a recent Benefits Magazine article, Jack M. Towarnicky, ERISA … Continued

In response to ongoing challenges within the No Surprises Act (NSA) framework, Rep. Greg Murphy (R-NC) and colleagues have introduced new legislation to close existing loopholes and enhance patient protection. This proposed bill (H.R.9572) focuses on increasing penalties for group health plans and health insurance providers who violate balance billing regulations, ensuring that patients are … Continued