Payer Contracting Episodes

I ask whether Theranos could be contracted by health plans today, and I argue that our current gates often check paperwork rather than test performance. I walk through four gates: CLIA certification, state and FDA rules, Medicare enrollment checks, and commercial payer contracting. I note that CLIA and state reviews eventually caught Theranos, but payers and investors did not detect the fraud. I explain that a reporter and regulators exposed the problem years into the misconduct, which shows a d...

This bonus episode is the full recording of Alex Yarijanian's HBMA continuing-education webinar. It runs longer than a standard VBCA episode — treat it as a resource, not a highlight reel.

Kids authorized for private-duty nursing often can't get home from the hospital because the pediatric home health network that looks adequate on paper — hundreds of agencies — shrinks to a handful (roughly 8 of 200 in NJ) that actually take high-acuity pediatric cases, turning "authorized hours" into a false promise.

Most revenue cycle teams are chasing the wrong fire. Persistent underpayment, denials that don't respond to appeals, patterns nobody can explain — these are often contract problems wearing a billing problem's disguise.

Got a contract. The fee schedule is fine. Not great — fine. And now the question isn't can we do this. It's should we, and on what terms?

CMS has posted the LEAD (Long-Term Enhanced ACO Design) model application materials. Most ACO applications fail before they're submitted — not because organizations are ineligible, but because they were never really built for risk.

Before you deploy capital into a tele-behavioral health market — run this checklist.

Rate sheets alone will mislead you. I've seen operators get into markets with strong Medicaid rates, only to get squeezed by high clinical labor costs, concentrated MCO power, or zero licensure compact coverage.

Why are employers paying up to four times Medicare rates for identical procedures? Dr. Kumar Dharmarajan joins Alex Yarijanian to break down incentive alignment, Medicare Advantage contracting, AI-driven engagement, and the structural pricing gap between MA and commercial markets.

In this episode, Alex Yarijanian breaks down what’s actually showing up in payer conversations right now, long before final CMS rules are published. Drawing from real contracting, network, and delegation discussions, Alex explains why waiting for regulatory clarity is already costing providers and health tech companies leverage.

This episode also outlines who is most at risk heading into 2026, the three types of organizations positioned to win, and what provider and health tech leaders should do in the next 90 days to stay relevant.

Welcome back to the Value-Based Care Advisory podcast! In this episode, host Alex Yarijanian delves into the significant updates and strategies for 2026 in the Medicare Advantage space. He covers essential news and policy changes, including a 5% increase in Medicare payment rates, the scaling back of supplemental benefits, and the permanence of telehealth for behavioral health. Alex also discusses updates to the Medicare physician fee schedule, redesigned enrollment forms, new health risk assess...

In this episode of the VBCA podcast, host Alex Yarijanian delves into the often overlooked yet crucial aspect of leadership: emotional labor. Discover how managing emotions plays a pivotal role in negotiations and leadership effectiveness. Alex shares personal experiences and insights on how emotional labor can be both a powerful tool and a silent tax on leaders, especially for those challenging dominant norms. Tune in to learn how to harness emotional intelligence to build trust and lead with e...

How Health Tech Startups Can Win at Managed Care Contracting: Insider Strategies for Scalable Payer Partnerships.
This episode dives deep into the essentials of navigating managed care contracts as a health tech startup.

Whether you're a founder, operator, or policy strategist, you'll walk away with a clear understanding of how to position your company for payer partnerships, structure risk-based contracts, and avoid common pitfalls in the healthcare financing space. We explore real-world examp...

The podcast delves into the complexities and challenges of the American healthcare system, arguing that it often prioritizes profit over patient care. Through the lens of investigative journalism from More Perfect Union, the hosts explore how companies like CVS Caremark and pharmaceutical giants manipulate the system to maximize their profits, often at the expense of those they are supposed to serve. They highlight the troubling trend of Medicare Advantage plans cherry-picking healthier patients...

The health insurance industry is confronting a convergence of rising healthcare costs, increased patient demand, and heightened legislative scrutiny as we approach 2025. Medicare Advantage plans, once highly profitable, are now under significant pressure due to these factors. Major insurers like Humana and UnitedHealth are experiencing challenges that may redefine managed care. However, this period of disruption presents opportunities for healthcare providers and entrepreneurs to innovate and adapt. By focusing on high-cost patient areas and exploring innovative contracts, stakeholders can position themselves to thrive in this evolving landscape.

Key Takeaways:

The health insurance sector is facing significant challenges due to rising costs and increased scrutiny.

Medicare Advantage plans are experiencing financial strain from surging patient demand and utilization rates.

Healthcare providers should analyze their patient populations to identify high-cost areas and develop …

In this episode of the VBCA Podcast, host Alex Yarijanian delves into the complex issue of hidden healthcare fees, surprise billing, and the alleged antitrust activities surrounding out-of-network reimbursements. The discussion centers on MultiPlan, a third-party repricing company accused of collaborating with major insurers—such as UnitedHealthcare, Cigna, and Aetna—to suppress out-of-network payments, adversely affecting patients, providers, and employers.

In this episode of the VBCA Podcast, host Alex Yarijanian and guest Dr. Chris Esguerra delve into the complexities of mental health parity, emphasizing the necessity for behavioral health services to receive the same level of care and coverage as physical health services. They discuss the challenges providers face when navigating insurance plans and the barriers to accessing equitable care for patients.

The system used to pay for health care today does not encourage the integration of health care and social care, nor can it adequately adapt to the trending shift toward value-based payments for care — paying for better quality and better health outcomes. New financing approaches are needed to enable the health care sector to engage in activities that strengthen social care and community resource.

This episode is also available as a blog post: https://healthcare-wiki.com/2021/07/21/paying-for-bi...

California Governor Gavin Newsom on September 25 signed Senate Bill 855, Health coverage: mental health or substance use disorders, into law. The law increases health and disability insurers' coverage obligations for mental health and addiction diagnosis, prevention, and treatment in the state.