Note:  We have shifted to a monthly cadence on these – each edition serves as a digest of payer/provider news from the prior month.

As always, this briefing is meant to keep us sharp on what’s changing around our clients, and where TREND’s expertise in collaborative accuracy can continue to lead the market.

Take a few minutes to scan the highlights below and note the areas that intersect most with your work.

Headline	Source & Link	Pub date	TL;DR	Why it matters (Provider / Payer)	What’s the pitch (TREND-aligned)
House Democrats move to repeal WISeR (AI-enabled PA pilot in Traditional Medicare)	Healthcare Dive — Democrats introduce bill to repeal Medicare prior authorization pilot (link)	10-Nov	Bill introduced to stop CMMI’s WISeR model adding prior auth (with AI tech vendors) in 6 states starting Jan; critics say it adds red tape and access risk. Healthcare Dive	Providers: Potential new PA burden (and algorithmic opacity) on previously PA-free services. Payers: Policy volatility—governance, auditability, and member impact must be buttoned up. Healthcare Dive	Recommend: TREND can assist with support on increased denials, as well as prevention strategies on new denial types. Level the playing field by deploying TREND tech-enabled services to find additional reimbursement opportunities.
CMS delays the new ASC prior auth demonstration; rolls out in phases Jan–Feb 2026	CMS — Prior Authorization Demonstration for Certain ASC Services (link)	20-Nov	Start shifted and phased (CA, FL, TN, PA, MD, GA, NY in Jan; TX, AZ, OH in Feb). Targeted procedures include bleph, botox, panniculectomy, rhinoplasty, vein ablation. CMS	Providers: Additional runway to prep workflows and documentation; prepay scrutiny coming.Payers: Opportunity to tune edits and reduce appeals churn before go-live. CMS	TREND can assist with support on increased denials, as well as prevention strategies on new denial types. Level the playing field by deploying TREND tech-enabled services to find additional reimbursement opportunities.
SNF audit: OIG says one facility’s claims failed requirements on99/100sample; $31.2M overpayment estimated	HHS-OIG — Pinnacle Multicare SNF audit (link)	18-Nov	First in new PDPM-era SNF audits: widespread documentation and coding failures; OIG recommends refund and internal lookbacks. Office of Inspector General	Providers: Expect PDPM documentation scrutiny; risk of significant takebacks.Payers: Reinforces need for targeted review of high-risk service lines. Office of Inspector General	Informational only
AMA meeting: CMS Administrator Oz defends cuts; nods to prior-auth pain points	Fierce Healthcare — ‘Come fight with me’—Oz courts physicians… (link)	19-Nov	CMS chief addressed physician pushback (PA burden, pay), while defending administration’s spending stance and MAHA agenda. Fierce Healthcare	Providers: Signals continued cost controls with pressure to streamline admin friction. Payers: Political headwinds make explainable PA/UM and member experience critical. Fierce Healthcare	Informational only

Signals we’re watching

• Prior auth volatility: WISeR faces repeal efforts; ASC demo delayed but imminent. Build flexible, auditable PA logic now. Healthcare Dive+1
• Federal recovery posture: OIG’s contract-closeout findings suggest broader rigor on improper payments across programs. Office of Inspector General
• PDPM enforcement: Early SNF audit results foreshadow a wider review wave hitting documentation/coding quality. Office of Inspector General
• Policy rhetoric → ops reality: CMS leadership is acknowledging PA pain while defending spend controls—expect pressure on accuracy and experience. Fierce Healthcare

Data you can cite

• WISeR repeal bill filed Nov 10, 2025 (6-state PA pilot with AI administrators).Healthcare Dive
• OIG: $11.2B at risk due to CMS contract closeout failures (issued Nov 17, posted Nov 19). Office of Inspector General
• CMS ASC PA demo delayed; phased starts Jan 19 and Feb 16, 2026. CMS
• SNF audit: 99/100 claims noncompliant; $31.2M estimated overpayment.Office of Inspector General
• CMS Administrator remarks at AMA Interim Meeting on Nov 19 (PA burden, budget stance).

Recent Payer-Provider Tension & Partnership Headlines

 
Quick Context What this means for TREND’s Audience UnitedHealthcare and SSM Health face split — contract lapse for 2026  UnitedHealthcare and SSM Health — a major hospital system — didn’t renew their contract. Starting 2026, SSM will be out-of-network for UHC’s commercial & Medicaid plans in Missouri/Illinois. Payers and providers at high risk of claim disruption, out-of-network surges, appeals, and member disruption. M Health Fairview / UnitedHealthcare contract dispute in Minnesota could leave ~125,000 patients in limbo  Contract negotiations stalled — coverage disruption possible if no agreement. Signals network instability; increased prior-auth exceptions, upfront verification needs, potential denials or high out-of-network spend. USA Health Providence Hospital and UnitedHealthcare fail to reach contract renewal — coverage ends Nov 15  Patients covered under UHC plans will lose in-network access at Providence Hospital unless a deal is struck. Major risk for patient disruption, claim anomalies, and bad debt from sudden OON billing.

 

What This Evolution Means and Why It Matters

• Contract instability is rising. These stories show that disputes aren’t confined to headline health systems, even regional hospitals and large payers are renegotiating (or walking away). That raises the risk of volume disruption, surprise bills, elevated denials, and financial backflow on both sides.
• Network churn increases friction at claims and admin layers. For providers: expect spikes in prior auths, appeals, out-of-network billing, patient uncertainty. For payers: expect higher leakage, administrative burden, and compliance complexity.
• Transparency and clean claims become competitive advantages. As negotiations and network shifts continue, payers/providers who can document accurately, bill cleanly, and manage transitions smoothly stand out.
• TREND’s full suite gets more strategic. Membership integrity, denial management, zero-balance reconciliation, coding validation, audit readiness, these become critical tools for organizations navigating network churn, contract disruption, and payment risk.