This month’s edition provides a focused review of newly approved and recently launched therapies. Expion Health monitors these developments closely to assess clinical relevance, therapeutic positioning, and potential implications for payers, providers, and patients. KEYTRUDA QLEX Indication KEYTRUDA QLEX (pembrolizumab and berahyaluronidase alfa) is approved for the treatment of 38 indications, including melanoma, non–small cell … Rx Insights from October ’25
Cigna’s announcement to shift away from prescription drug rebates for its fully insured plans in 2027 and for Express Scripts’ customers in 2028 is another signal of ongoing change in how pharmacy economics may be structured in the future. The transition from post-sale rebates to up-front discounts has the potential to redefine how value is measured … Cigna’s Plan to Shift from Drug Rebates: What it Could Mean for Pharmacy Strategy — and a Call to Action for Smarter Pharmacy Strategy
This month’s edition provides a focused review of newly approved and recently launched therapies. Expion Health monitors these developments closely to assess clinical relevance, therapeutic positioning, and potential implications for payers, providers, and patients. WAYRILZ Indication WAYRILZ (rilzabrutinib) is a kinase inhibitor approved by the FDA on August 29, 2025, for the treatment of adults … Rx Insights from September ’25
It’s not uncommon for facilities or PPO networks to assert that a claim is DRG-based to deter payors from pursuing further review. On the surface, this might seem like a dead end for an Itemized Bill Review, but that’s not always the case. When informed that a claim was repriced at a DRG, it’s crucial … The Power of Probing: Why You Should Question DRG-Based Claims
The concept of ethical administration has rapidly become a hot topic – so much so that it is the theme of this year’s Health Care Administrators Association (HCAA) TPA Summit. This post, inspired by insights from Nicholas Stone, SVP, Medical Cost Containment Sales at Expion Health, examines what constitutes “Ethical Administration,” aiming to highlight the … Choosing the Right Partners: Administrators’ Quest for Vendors Committed to Ethical Administration in Non-Network Claims
In the changing landscape out-of-network (OON) medical claims, health plans & TPAs face the dual challenge of managing costs while ensuring fairness and transparency. A recent New York Times article spotlighting practices by certain industry players has intensified concerns regarding the management of OON claims. Such revelations underscore the importance of adopting business practices that … Navigating Shifting Market Expectations: Enhancing OON Claim Repricing Fairness and Transparency
Expion Health’s analysis of the latest CMS report from February 2024, which sheds light on the Independent Dispute Resolution (IDR) process for No Surprises Act (NSA) cases. for the first half of 2023, uncovered a particularly interesting finding: plan dollars are being wasted on what we have termed “no-response” claims. These occur when health insurance … NSA No-Response IDR Determinations a Surprising Waste of Plan Dollars
A central theme emerged, at the HCAA Executive Forum: the imperative for TPAs to evolve as a fiduciary-like partner for their groups and their employees. In this dynamic landscape, the call for transparency and control in medical claims and administrative costs has never been louder or clearer. A New Paradigm for TPAs In the face … Harnessing Transparency and Control: Key Takeaways from the HCAA Executive Forum from Expion Health
The Federal government recently proposed changes to the NSA IDR process in hopes of holding all involved organizations more accountable and forcing initiating and non-initiating parties to be more diligent in documentation and timely admin fee payments. While the end goal may be to increase speed, efficiency, tracking and transparency, the immediate result is health … Get Ready: CMS Proposes Numerous Changes to IDR Process
NSA currently excludes Urgent Care and Ground Ambulance services despite pressure to do so. However, some states have begun to provide protection. This means self-funded employers must determine which coverage to use. What may seem like the right path may not always make the most economic sense. To ensure the best savings, self-funded plans should … NSA Minute: Ground Ambulance & Urgent Care Services
Blue Shield’s shift from a single PBM to multiple specialized partners for pharmacy benefits management has health plans wondering if disaggregation is right for them. At Expion Health, we’re here to highlight why this shift matters and how we can support health plans like yours with this strategy. 1. Strategic Alignment: Partnering Without Conflict Moving … Blue Shield of California Pharmacy Shake-Up: 3 Disaggregation Considerations for Health Plans
There are 5 costly challenges payers still face when it comes to NSA claims. These challenges are exposing payers to compliance risks and upsetting members. Expion Health’s NSA Navigator is designed to solve those challenges. Don’t expose yourself to NSA compliance and member satisfaction risks. Understand the top challenges payers face and how to solve … Top 5 NSA Challenges & Solutions for Payers
Payers grapple with the complexities of the No Surprises Act (NSA), but self-insured plans face an added challenge in states that allow plans opt-in to state laws instead of the federal law. Selecting between state or federal laws demands careful analysis of factors such as: breadth of protections, data inputs allowed for payment determinations, claims … Navigating the No Surprises Act: The State vs. Federal Balance Billing Dilemma
Independent dispute resolution (IDR) has gained remarkable popularity among healthcare providers since the implementation of the No Surprises Act (NSA). The statistics from the first year of the NSA reveal an unexpectedly high volume of IDR cases—14 times more than initially projected. As of March 31, 2023, IDR entities have issued a substantial 42,158 payment … Inside the Numbers: The Surging Popularity and Impact of IDR under the No Surprises Act
The Independent Dispute Resolution (IDR) process for NSA continues to deliver surprises and complexities for payers. For example, in a February IDR ruling, a provider was required to refund money to a payer! A successful IDR outcome requires a strong strategy. It’s essential to have a skilled team that is current on IDR guidance and … NSA Minute: IDR Surprises
Legal challenges to the No Surprises Act (NSA) continue to arise with six lawsuits brought forth so far. One lawsuit challenging the constitutionality has failed, but challenges to the regulations used to enforce the statute have continued to erode timely decisions in the independent dispute resolution (IDR) process. Another is challenging the QPA methodology around … NSA Minute: Impact of Legal Challenges
At the end of 2022, half of hospitals are in the red — putting pressure on hospitals to look for new opportunities to increase revenue. This year, OIG added to the pressure with transparency in coverage enforcement and by looking at hospitals seeking to obtain bad debt recoveries from CMS. All of this is compounded … NSA Minute: Hospitals’ Financial Strategy
As we follow the impact of NSA, we continue to see unexpected scenarios occur. For example, with out-of-network at an in-network facility or even emergency care, we assume this excludes office visits. However, recently it has been shown that there are unique instances where office visits could fall under NSA around radiology and clinical lab. … NSA Minute: Unexpected Scenarios
The recent No Surprises Act’s (NSA) report from HHS, Department of Labor, and Department of the Treasury presented eye-opening statistics about the impact and challenges of independent dispute resolution (IDR). Harnessing the power of our NSA claims processing technology, we are helping clients navigate these challenges by calculating defensible QPAs, identifying claims that are ineligible for IDR, … NSA Minute: Eye Opening IDR Statistics
As our hearts and prayers go out to Damar Hamlin and his family for a speedy recovery after his on-field medical emergency, we are reminded of the complexities of emergency care, especially if ongoing care is needed. Even after the immediate crisis has passed, post-stabilization care may still be needed. The No Surprises Act has been instrumental … NSA Minute: Separating NSA and Post-Stabilization Codes
Calculating accurate QPAs is difficult and mistakes can be costly and create compliance risks. Here’s what to do.
The use of biosimilar products in lieu of originator biologic products has been a hot topic of discussion since the first FDA approval of Zarxio (a biosimilar for Neupogen) in 2015. Since then over 30 new biosimilars have been FDA approved but the biosimilar market hasn’t taken off as expected. The slower than expected uptake … The Impact of Humira Biosimilars: 5 Factors That Will Reduce Payer Costs
The biologics market could see some significant changes with the current and upcoming interchangeability approvals of several biosimilar products. Let’s dive into what biosimilars are and the importance of interchangeability. What is a biosimilar?A biosimilar is a potential alternative for an existing FDA-approved biologic. They are highly similar (can have minor differences in inactive components) … Biosimilars 101
