Healthcare provider network and plan design
The provider network and plan design refers to the configuration of healthcare providers and the structure of health plans offered to patients. Effective network and plan designs are crucial for ensuring accessibility, affordability and quality of care for healthcare consumers. The elements directly affect cost management, quality of care and member satisfaction.
Top Stories
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News
28 Apr 2026
AMA alerts officials of health plans' No Surprises Act abuse
More than 100 provider groups call for greater enforcement of the No Surprises Act after accusing health plans of circumventing its intent and raising patient costs. Continue Reading
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News
27 Apr 2026
Payers promise standardized electronic prior auths
After announcing an 11% reduction in prior authorizations, major payers are now focusing on standardizing an electronic request process. Continue Reading
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News
23 Apr 2026
Prices rose after No Surprises arbitration for some care: analysis
The data, compiled by the Brookings Center on Health Policy, shows that average prices for some services like imaging were seven-times higher than Medicare prices. Continue Reading
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News
22 Apr 2026
When brand-name drugs need a prior auth, brace for delays
A study uncovered friction at the pharmacy, revealing days-long delays and frequent denials when brand-name prescription drugs need a prior authorization. Continue Reading
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News
20 Apr 2026
Judge dismisses Aetna’s No Surprises fraud suit against Radiology Partners
The insurer accused the radiology group of gaming the No Surprises Act to reap higher reimbursement. A judge tossed the case last week. Continue Reading
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News
16 Apr 2026
Before revenue cycle AI, payers and providers need to get along
A survey shows that most providers say disagreements with payers over claims prevent timely and full reimbursement. Continue Reading
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News
14 Apr 2026
Judge dismisses No Surprises Act lawsuit against HaloMD
A California federal court threw out Elevance Health's lawsuit against HaloMD, alleging the organization has gamed the No Surprises Act's IDR process for profit. Continue Reading
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News
08 Apr 2026
Jefferson Health sues Aetna over Medicare Advantage ‘downcoding’ policy
The health system claims the policy, which reduces reimbursement for some inpatient hospital stays, violates federal law and its reimbursement contract with Aetna. Continue Reading
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News
08 Apr 2026
Major payers say they cut prior authorizations by 11%
Major Blues plans, Cigna, Humana and United are among the payers reporting reduced prior authorizations amid an industry-wide push to streamline the process. Continue Reading
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News
25 Feb 2026
New report shows NSA is working. So, why are payers, providers still mad?
A new report suggests greater in-network participation since the No Surprises Act, but more work needs to be done to iron out the law's wrinkles for major stakeholders. Continue Reading
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News
24 Feb 2026
GoodRx offers employers a workaround for GLP-1s, high-cost meds
A new service will allow employers to provide direct subsidies for high-impact, brand-name medications, like GLP-1s, without adding coverage to their insurance plans. Continue Reading
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News
28 Jan 2026
Half of providers report revenue losses from credentialing delays
Credentialing delays are costing some hospitals over $1M annually as provider organizations face workforce challenges and manual processes. Continue Reading
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News
15 Oct 2025
Private payers also pay a lot more for HOPD vs ASC care
A new study finds private payers, similar to Medicare, pay significantly higher rates to HOPDs for common services, although a narrow network led to savings for one national payer. Continue Reading
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News
25 Sep 2025
Which SDOH do seniors want health plan benefits to address?
Aging in place, access to healthcare and economic insecurity are leading SDOH affecting senior health and wellbeing. Continue Reading
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Feature
24 Sep 2025
Breaking down the ABCs of rising alternative health plans
More employers are seeking alternative health plans, like AHPs and ICHRAs, to bend the cost curve, but education is key to navigating their growing popularity. Continue Reading
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Feature
16 Jul 2025
UnitedHealthcare's provider search tool hinges on consumerism
UnitedHealthcare designed its provider search tool to fulfill the growing demands of healthcare consumerism while nudging the user toward high-value providers. Continue Reading
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News
04 Mar 2025
Commercial insurance coverage for GLP-1s still limited
Fewer insured people have coverage for GLP-1s, while more are beholden to prior authorization and step therapy before gaining access to the drugs. Continue Reading
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Feature
27 Feb 2025
How companies find solutions to employer GLP-1 coverage
Employer GLP-1 coverage has serious cost barriers, but some companies are turning to technology vendors to provide a comprehensive approach to access. Continue Reading
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Feature
24 Feb 2025
Employers seek healthcare price transparency to control costs
Navigate rising costs by leveraging healthcare price transparency, direct provider contracts and data access, despite ongoing challenges for employers. Continue Reading