Wakely Wire

New Insights

Whitepapers, briefs, press releases and more

From Premiums to Performance: Managing Risk in Self-Funded Health Plans

This brief is the second in a series outlining the fundamentals of self funding. It highlights key steps to successfully establish and manage a self funded health plan, with a focus on funding strategy, risk management, and cost control, and explores alternative funding approaches such as level funding, HRAs, captives, and trusts.

Continue reading

Week in Washington 05/28/26

Medicaid Regulation Watch: All eyes are on CMS as it prepares for the release of the Medicaid work requirements regulation. One of the key questions is what flexibilities states will have around the definition of medical frailty. The work requirement law requires states to exempt from work requirements individuals who are medically frail.  KFF has ... Continue reading

Continue reading

Newsworthy Findings

Ōura Files for IPO Amid Healthcare Push

The smart ring maker’s filing follows a recent $900 million fundraise and comes amid plans to develop more health features for the device.

Read full article
Editor's Note
Ōura’s wearables already track health metrics such as temperature, heart rate, and sleep, but the company is pushing further into health monitoring. It is working with the FDA on a study for a feature that could help identify early signs of hypertension. The IPO filing also comes as the company scales quickly: in October, Ōura said it had sold more than 5.5 million devices and expected 2025 revenue to exceed $1 billion

HHS Launches AI-Backed Health Fraud Crackdown

The department will use AI to examine audits from states and other federal grant recipients, and potentially withhold funds if they aren’t able to fix errors.

Read full article
Editor's Note
The Audit Enforcement and Risk Oversight program follows years of concerns over weak follow-through on HHS audits. Gustav Chiarello, HHS’s assistant secretary for financial resources, said states and grantees have faced little accountability despite audit reports flagging serious vulnerabilities and failures. The move also builds on CMS’s broader fraud crackdown, including a recent freeze on new Medicare enrollments for hospice and home health providers aimed at reducing fraud, waste, and abuse.

Hospitals Sue CVS for Allegedly Siphoning $250M In 340B Funds

The hospitals allege CVS artificially deflated reimbursement for 340B drugs and caused them to lose $250 million in savings over five years.

Read full article
Editor's Note
Hospitals owned by Mount Sinai, University of Michigan Health, and the University of Kansas filed lawsuits accusing CVS and its pharmacy subsidiaries of manipulating reimbursement rates for 340B drugs and keeping the difference as profit. The hospitals claim CVS identified claims as 340B-eligible only after insurers had already paid full rates, then reduced hospital reimbursement through affiliated PBM and pharmacy operations. The lawsuits add to broader scrutiny of PBMs and ongoing debates over transparency and reform in the drug pricing system.

ACAP Warns Final ACA Rule Adds Further Uncertainty to a Market in Flux

ACAP warned that the Trump administration’s delayed ACA marketplace rule is adding uncertainty to the 2027 bid process and could destabilize exchange markets by expanding non-network and catastrophic plans that may weaken consumer protections and risk pools.

Read full article
Editor's Note
ACAP raised concerns that CMS finalized the ACA marketplace rule much later than usual, forcing health plans to adjust their 2027 bid strategies under compressed timelines and incomplete information. The group also warned that expanded access to non-network and catastrophic plans may attract healthier members away from traditional Marketplace coverage, potentially harming market stability and exposing consumers to higher out-of-pocket costs and more complicated coverage decisions. The changes come as ACA exchanges are already dealing with premium increases and uncertainty tied to expiring post-pandemic subsidies.

CMS Finalizes Changes to No Surprises Act Dispute Resolution Process

CMS finalized a rule updating the No Surprises Act’s dispute resolution system by lowering administrative fees, enabling batched claims, and introducing a centralized IDR Gateway to improve efficiency amid high arbitration volumes.

Read full article
Editor's Note
These operational updates could streamline workflows and reduce administrative burden for both providers and payers navigating the dispute process. Since April 2022, more than 5 million disputes have entered the IDR system, far exceeding original expectations.

Bonus Article

Just for Fun

Math Joke:

How do you make seven an even number?

Prior Week

Q: Why did the mathematician break up with the calculator?

A: Because she felt like he was only using her for solutions

Sign up for the
Wakely Wire,

our industry newsletter.