Health Insurance Industry Issues and Legislation

H.H.C. Group slashed an out-of-network laparoscopic surgery claim from $343,638.80 to $68,000, saving the client over $275,000—an 80.2% reduction—in just three business days. The case involved a complex procedure for a rare anatomical condition, and H.H.C.'s attorney case manager secured the agreement through expert review and direct provider negotiation. This case demonstrates H.H.C. Group's ability to deliver rapid, substantial savings on high-dollar claims.

H.H.C. Group announces that it has been re-approved by multiple states for which it currently conducts Independent Medical Reviews (IMRs), typically for disputes regarding coverage by payors based on medical treatment necessity or appropriateness. These state designations reinforce H.H.C.'s position as a high quality URAC-accredited Independent Review Organization (IRO) and highlight the company's vital role in helping payors resolve claim disputes efficiently, compliantly and with clinical precision.

Demand for GLP-1 drugs like Ozempic and Wegovy is skyrocketing, creating serious cost pressure for employer-sponsored health plans. With usage expanding beyond diabetes to conditions like obesity and sleep apnea, many plans are struggling to manage downstream medical claims and protect their financial sustainability. H.H.C. Group helps mitigate the impact through independent medical reviews, expert negotiation on high-cost claims, and detailed line-item bill reviews—ensuring clinical appropriateness, reducing overpayments, and reinforcing fiduciary compliance.

H.H.C. Group's new white paper, Managing High-Cost Healthcare Claims, offers actionable strategies for payors, TPAs, self-funded employers and stop-loss carriers to combat rising claim costs—up 45% since 2019—and mounting regulatory complexity. From specialty drug management to attorney-led negotiations and URAC-accredited reviews, the resource outlines proven, data-driven tools to reduce expenses, ensure compliance and improve financial sustainability.

Many physicians are concerned that the increasing use of unregulated AI in health insurance could lead to more prior authorization denials and negatively impact patient care, according to the American Medical Association's (AMA) latest survey. The report highlights that three in five physicians worry that AI exacerbates patient harm and healthcare inefficiencies. The AMA advocates for the use of AI as "augmented intelligence," stressing the need for human oversight in medical decision-making to prevent the systematic denial of necessary treatments.

The U.S. House of Representatives has passed Congressman Vern Buchanan's Chronic Disease Flexible Coverage Act, which allows employers offering high deductible health plans (HDHPs) to include pre-deductible coverage for 14 chronic healthcare services. This legislation aims to improve management of chronic diseases by reducing out-of-pocket costs for essential treatments, enhancing patient health, and has garnered unanimous bipartisan support. The bill codifies policies from the Trump Administration and now awaits further consideration in the Senate.

A recent study by the RAND Corporation, published in Health Affairs, highlights the significant financial impact of upcoding on Medicare, costing billions over nearly a decade. Upcoding occurs when healthcare providers bill for a higher level of care than was necessary, sometimes due to errors or, in other cases, as outright fraud. The study, which analyzed hospital data across five states and 240 medical conditions from 2011 to 2019, suggests that much of the growth in billing for high-level hospital discharges—estimated at 41%—could not be fully explained by patient care complexities, hinting at prevalent upcoding practices.