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Twice-Weekly Briefing
Friday, October 9, 2026
Issue 261009-70
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The MOC Brief
Health policy, priced and translated for self-funded plan sponsors
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In This Edition
Five developments from the past ten days, and what each one costs you.
| 1. | Hospitals posted a zero allowed amount count on 95 percent of commercial entries priced as a percentage of charges. | | 2. | A federal audit measured what four vertically integrated Part D sponsors route to pharmacies they own, about 28 percent of volume. | | 3. | Cigna will start rolling out an AI care guide in early 2027 and projects a 10 percent cut in inefficient spending by 2030. | | 4. | Sentara ended Anthem talks on three plan lines and says employer coverage is still being negotiated. | | 5. | A federal fraud task force and OPM reported $237.7 million in carrier-reported savings stopped before claims were paid. |
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| 1 · Price Data · October 7, 2026 |
| Hospitals Posted a Zero Allowed Amount Count on 92 Percent of Commercial Entries Priced by Algorithm |
| The Peterson-KFF Health System Tracker published the first read on the new hospital price transparency fields on October 7, 2026, in an issue brief by Gary Claxton, Lynne Cotter, Shameek Rakshit and Matthew Rae. Looking across 6,445 hospitals that have uploaded machine-readable files under version 3 of the reporting schema, the allowed amount count was zero in 92 percent of instances in commercial plans for MS-DRG entries when a negotiated algorithm was encoded, and in 95 percent of the instances when a negotiated percentage was encoded. Narrowed to two common codes, MS-DRG 280 for acute myocardial infarction discharged alive with multiple chronic conditions and MS-DRG 807 for vaginal delivery without sterilization or D and C without complications, the zero share was 72 percent for a negotiated algorithm and 91 percent for a negotiated percentage. Peterson-KFF reports all of these as shares of posted entries rather than shares of hospitals, and its text does not give the number of entries behind them. The analysis used files processed and maintained by Turquoise Health, downloaded between July 17 and August 2, 2026. The authors note that hospitals can update their files at any time, so the examples shown may no longer represent the most recent information those hospitals report. |
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MOC Perspective
The allowed amount count is the claim volume sitting behind a posted price. Without it, a negotiated algorithm or a percentage of charges is a formula with nothing to apply it to, and even the two common codes Peterson-KFF examined closely were missing the count on 72 percent of algorithm entries. Your consultant can still quote you a rate off these files, so the question to ask is who checked the count before that number reached your renewal model. This is a question, not a project.
What to do now
| ▪ | Ask your consultant in writing which machine-readable files it pulled and whether the allowed amount count was populated, before you sign 2027 renewal paper. | | ▪ | Pick the five highest-volume inpatient codes your members used last plan year and read the posted entries for each of your top three hospitals yourself. | | ▪ | Require any reference-based pricing or steerage proposal to name its data source and download date, with a 30-day deadline for the answer. |
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| Source: Peterson-KFF Health System Tracker, issue brief of October 7, 2026 |
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| 2 · PBM Oversight · October 6, 2026 |
| A Federal Audit Found Cost Sharing Up to $340 Higher at Owned Pharmacies on About Half the Costliest 20 |
| The Government Accountability Office reissued GAO-26-107393, its report on payments and contracts between pharmacies and vertically integrated Medicare Part D plan sponsors, with revisions on October 6, 2026, having published it September 3 and released it publicly October 5. The revision note reads that it was revised October 6, 2026 to correct the percentages in the second sentence of the Highlights page. GAO found that, for four large Part D plan sponsors, the pharmacies they owned accounted for about 28 percent of the Part D drugs they provided to their enrollees and about 24 percent of the total payments to pharmacies in 2023. When those sponsors paid pharmacies for a 30-day supply of the 100 most commonly used prescription drugs, payments and cost sharing for at least 94 percent of these drugs were lower for owned pharmacies than for non-owned pharmacies, and average payments for a 30-day supply of most were $10 or less. Payments and cost sharing were also generally lower at owned pharmacies for the 100 drugs with the highest total payments in 2023, which were primarily brand-name drugs, but GAO reports that for some of those drugs payments or cost sharing were higher at owned pharmacies. Its example is that cost sharing across the four sponsors was up to about $340 higher at owned pharmacies for about half of the 20 drugs with the highest payments per 30-day supply. The four sponsors accounted for over 40 percent of total Part D enrollment in 2023, and GAO states that its results are not generalizable to other plan sponsors or years. This is Medicare Part D, and the words commercial, employer and self-funded appear nowhere on the report's product page. |
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MOC Perspective
Nothing here measures your plan. The method transfers: split your own pharmacy claims by whether the dispensing pharmacy is owned by your PBM, then read the cheap high-volume drugs and the costliest brands separately. GAO found owned pharmacies came in lower on both groups, on at least 94 percent of the 100 most common drugs, with real exceptions among the most expensive, where the member sometimes paid more. The exceptions are where your money sits, and your consultant can find them in claims you already hold.
What to do now
| ▪ | Ask your PBM for a 12-month report splitting dispensing volume and member cost sharing by whether the pharmacy is owned by the PBM or its parent. | | ▪ | Pull your 20 highest-cost drugs by payment per 30-day supply and compare member cost sharing at mail, specialty and retail, within 30 days. | | ▪ | Put a standing right to that owned-versus-unowned split into your next PBM agreement, before 2027 contract paper closes. |
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| Source: U.S. Government Accountability Office, GAO-26-107393, reissued with revisions October 6, 2026 |
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| 3 · Payer AI · October 6, 2026 |
| Cigna Will Start Rolling Out an AI Care Guide in Early 2027 for Oncology and Cardiometabolic Needs |
| Cigna Healthcare announced Health Sense on October 6, 2026, and said it will begin rolling it out in early 2027, initially for customers with oncology and cardiometabolic health needs. The company describes it as an artificial intelligence layer connecting guidance, benefits and support, and says it is projected to reduce inefficient health care spending by 10 percent by 2030. A companion Cigna page is explicit that this is a forward-looking projection and not a measured Health Sense result, and that it is not a projected 10 percent reduction in total health care spending; Cigna puts the share of health care spending that is inefficient at roughly one third. Cigna also states that Health Sense does not diagnose conditions, prescribe or modify treatment, or replace a treating provider, and that treatment decisions remain between customers and their treating providers. The results the announcement cites belong to existing Cigna programs rather than to Health Sense, including provider engagement 44 to 80 percent higher depending on the program, $5,851 in annual savings among customers who met oncology care management goals, and a 37 percent increase in colorectal cancer screenings. The clinical content is described as validated by Cigna Healthcare physicians, nurses, pharmacists, behavioral health specialists and care management teams, and no outside validator is named. Neither page says whether self-funded clients are in the first wave. |
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MOC Perspective
Early 2027 lands inside the plan year you are negotiating now, and nobody at Cigna has said in public whether your funding arrangement is in that first group. That is the question for your Cigna representative this week, in writing. The 10 percent is a projection against the inefficient third of spending rather than a cut to your budget, so do not let it arrive in a renewal deck as savings. The guardrails are the useful part, and they belong in your service agreement rather than a press release.
What to do now
| ▪ | Ask your Cigna representative in writing whether your funding arrangement is in the early 2027 rollout, with a two-week deadline for the answer. | | ▪ | Require the no-diagnosis and no-treatment-change guardrails to appear in your administrative services agreement before you sign for 2027. | | ▪ | Strike any projected savings figure from your renewal model, and set a 30-day deadline for Cigna to say when a measured result will exist. |
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| Source: Cigna Healthcare newsroom, announcement of October 6, 2026 |
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| 4 · Network Contracts · October 5, 2026 |
| Sentara Ended Anthem Talks on Three Plan Lines and Says Employer Coverage Is Still Being Negotiated |
| Sentara Health updated its Anthem contract page on October 5, 2026 to say that after nearly a year of negotiations, Anthem has failed to accept a fair, sustainable agreement that would keep Sentara providers in network for Anthem's Medicare Advantage, Medicaid and ACA Exchange members after 2026. Sentara writes that it has ceased negotiations for these plans and is preparing for affected members to transition to out-of-network status beginning in 2027. Medicare Advantage and ACA Exchange members move out of network January 1, 2027, and Medicaid members January 28, 2027. On employer coverage the page says two things: that commercial, employer-sponsored plans are currently unaffected by this change, and that Sentara is still negotiating for commercial, employer-sponsored plans and continues to work toward a fair agreement that keeps these patients in network and preserves their choice of provider. All Anthem members can continue to see Sentara providers and use Sentara facilities in network through at least December 31, 2026. Sentara says it serves nearly 380,000 Anthem members across Virginia, which is its count of all Anthem members in the state and not the employer subset. Sentara's page gives no expiration date for the commercial contract, while Anthem's own page lists conditional commercial exit dates of December 31, 2026 for Tidewater and Eastern Virginia facilities, physicians and ancillary providers and December 31, 2027 for other facilities, if no new agreement is reached. Anthem's page carries no publication date, so only Sentara's account of this dispute can be dated, and the two sides put different numbers on what Sentara is asking for, so neither figure runs here. |
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MOC Perspective
Three of four plan lines are finished and yours is the one still at the table. Sentara says your Virginia employees are in network through at least December 31, 2026 and publishes no commercial expiration date, while Anthem publishes conditional exit dates on a page that carries no date of its own. Neither of those is the contract. Ask Anthem for the commercial contract's expiration date in writing now rather than in December.
What to do now
| ▪ | Ask Anthem in writing for the Sentara commercial contract's expiration date, with a 14-day deadline for a written answer. | | ▪ | Count how many of your Virginia members used a Sentara facility in the last 12 months, and name the nearest in-network alternative for each service line. | | ▪ | Draft the member transition notice now and hold it, because you may get days of warning rather than weeks. |
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| Source: Sentara Health, Anthem contract member update, updated October 5, 2026 |
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| 5 · Program Integrity · September 29, 2026 |
| The White House Fraud Task Force and OPM Reported $237.7 Million Stopped Before Claims Were Paid |
| The White House Task Force to Eliminate Fraud and the Office of Personnel Management announced more than $500 million in anti-fraud savings for calendar year 2025 in the Federal Employees Health Benefits and Postal Service Health Benefits Programs, in a release dated September 29, 2026. The release labels these as carrier-reported results, made up of recoveries, actual savings and estimated prevented losses. Of that total, $237.7 million was saved from claims stopped or reduced before payment, an additional $271.9 million in losses were prevented due to changes in billing and policy, and an additional $21.9 million were recovered after payment. OPM Director Scott Kupor is quoted saying that fraud in federal health benefits programs drives up costs for employees, retirees and taxpayers. The release page carries no date of its own, and the date appears only on the OPM release index. It gives no count of enrollees, carriers or cases, states no combined total beyond more than $500 million, and never uses the words employer, ERISA or self-funded. |
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MOC Perspective
These are not ERISA plans, so nothing here binds your plan. The method is what you want, with one caution: every figure is a carrier's own count of what it says it saved. Three numbers tell you where an anti-fraud program actually works, and $21.9 million, the money that came back after it had already gone out the door, is the smallest of the three. Ask your TPA to split its own fraud results the same three ways, because a TPA that can only show you post-payment recoveries is telling you its program is back-end only.
What to do now
| ▪ | Ask your TPA to report last plan year's fraud results in three figures: claims stopped before payment, losses prevented by billing or policy change, and dollars recovered after payment. | | ▪ | Set a 30-day deadline for that answer, and put the three-way split into your next administrative services agreement. | | ▪ | Count how many pre-payment edits your TPA runs on your claims today, and ask what it would cost to add the top three it does not. |
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| Source: U.S. Office of Personnel Management, news release dated September 29, 2026 on the OPM release index |
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The Bottom Line
Every one of these five rests on a number somebody else produced: the hospital's posted entry, GAO's dispensing split, Cigna's 2030 projection, Sentara's account of this dispute, and the savings OPM's carriers reported. Three of the sources say as much themselves. GAO states that its results are not generalizable, Cigna calls its 2030 figure a projection rather than a measured result, and OPM labels its totals carrier-reported and its prevented losses an estimate. Peterson-KFF simply never prints the number of entries behind its shares. The work this week is not finding better numbers. It is writing down, for each figure you already rely on, who produced it and who checked it.
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Jude Odu
Founder and Principal, Model Optimal Care
Author of Model Optimal Care: End U.S. Healthcare Waste, One Health Plan at a Time
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