Wakely Wire
August 28, 2025
New Insights
Whitepapers, briefs, press releases and more
Week in Washington 08/28/25
Integrity Rule Injunction Program A federal judge issued a ruling placing a temporary injunction on several portions of CMS’s recently finalized Program Integrity Rule. Notably, the injunction would void the changes to the AV de minimis levels, $5 minimum net premium, SEP verification, failure to reconcile ban, additional verification for income, and past due premium ... Read more
2024 Supplemental Claims Impact
ACA risk scores increased by nearly 6% due to supplemental claims in the ACA individual market. This translates to roughly $3,000,000 ($30 PMPM) for a 10,000 member population. The 6% also represents a steady increase in supplemental claims impact and doubles the 2019 impact. Issuers should review and benchmark their data against the industry to ... Read more
Events & More
Join Wakely at HMA’s National Conference, “Adapting for Success in a Changing Healthcare Landscape,” October 14-16 at the Four Seasons New Orleans.
This year’s event comes at a pivotal time. The recent enactment of the 2025 Budget Reconciliation Act marks the most significant federal healthcare reform since the Affordable Care Act. The law introduces sweeping change to Medicare, Medicaid, and the ACA Marketplace, with far-reaching effects for hospital and provider revenues, payer strategies, life sciences and health technology organizations, as well as patients. For those focused on the effects and implementation of federal policy changes, this is an opportunity to engage with leaders shaping the future of healthcare.
Featured Sessions for Actuarial Clients
Medicare Models, Markets, and Momentum: What They Mean for Payers, Providers, and Investors led by Tim Murray, FSA, MAAA, Principal, Wakely, an HMA Company, will focus on policy shifts reshaping the MA landscape, including the expansion of RADV audits, evolving expectations around coding accuracy, use of AI, and CMS’s push for more meaningful value-based arrangements.
Delivering on the Promise of Payment Reform: Operational Strategies for Success Led by Kate de Lisle, Principal, Leavitt Partners, an HMA Company, this session dives into the operational realities of value and risk-based payment models.
Check out our list of speakers
Newsworthy Findings
No Surprises Dispute Resolution is Creating Billions of Dollars in Extra Costs, Could Raise Premiums: Analysis
Providers are turning to the law’s arbitration process in droves to settle out-of-network claims, one factor fueling spending that could cost consumers down the line.
Johns Hopkins Goes Out Of Network With Unitedhealthcare After Failed Contract Negotiations
The Baltimore-based system and the major insurer failed to resolve their contract spat by Monday’s deadline, sending some 60,000 patients out of network. Both pledged to continue negotiations.
Rising Drug Costs are Threatening the Future of Employee Benefits – Here's How to Fight Back
Pharmacy costs are the fastest-growing component of health benefits with total pharmacy spending up 11.4% in 2024 compared to 2023. The pharmacy benefits market is likely on the verge of a major upheaval, particularly with continued uncertainty around rising drug costs.
DOJ's Criminal Probe Into UnitedHealth Extends to Optum Rx, Physician Reimbursement: Report
The Department of Justice's ongoing criminal investigation into UnitedHealth Group extends beyond Medicare Advantage.
Medicare Advantage Plans Pay Physicians Less than Original Medicare
MA pays 10% to 15% less than what is paid by the government in original Medicare, report says.
Bonus Article
Washington to Protect the Old-Growth Forests of Tomorrow, Creates 77,000 Acres of ‘Legacy Forests’
Just for Fun
Math Joke:
In life, what’s the one thing you can always count on?
Prior Week
Q: Why don’t prime numbers ever get along?
A: Because they can’t find any common factors.
Sign up for the
Wakely Wire,
our industry newsletter.
