The Regulator

25 percent: that is the highest share of Affordable Care Act marketplace prior authorization requests one insurer denied last year, in the first federal data set that lets patients compare denial rates insurer by insurer. KFF published an analysis August 13, 2026 of prior authorization data that a 2024 Centers for Medicare and Medicaid Services (CMS) rule forced 14 major insurers to publicly post for the first time, covering roughly 71 million enrollees across Medicare Advantage, Medicaid managed care, and Affordable Care Act (ACA) Marketplace plans. Standard-request denial rates averaged 12 percent in Medicare Advantage, 14 percent in Medicaid managed care, and 18 percent in the ACA Marketplace, but individual insurers varied far more widely: UnitedHealth denied 17 percent of Medicare Advantage requests versus Elevance’s 5 percent, Independence Health Group denied 23 percent of Medicaid requests versus L.A. Care’s 2 percent, and Centene denied 25 percent of ACA Marketplace requests versus GuideWell’s 3 percent. When patients did appeal a denial, insurers reversed themselves 67 percent of the time in Medicare Advantage, 47 percent in Medicaid managed care, and 43 percent in the ACA Marketplace, evidence that many initial denials do not hold up, even though few patients ever file an appeal. Confidence: High. This run reviewed KFF’s own published analysis directly. Sources: Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain, KFF.

Third: that is how many doctors President Trump has now approached to run the Food and Drug Administration, after two others turned the job down before this week’s pick took it. President Trump announced August 19, 2026 that he will nominate Dr. Heidi Overton, deputy director of the White House Domestic Policy Council, to become the next FDA Commissioner, filling a post vacant since Dr. Marty Makary left in May. Overton, a physician who trained in general surgery at Johns Hopkins and holds a PhD in clinical investigation, would take over an agency that decides which drugs, vaccines, and medical devices reach the market and on what timeline, work with direct billion-dollar stakes for patients and industry alike, and one now entangled with the vaccine-recommendation overhaul this newsletter covered yesterday. According to a senior administration official cited in press reports, former Rep. Brad Wenstrup and acting Commissioner Kyle Diamantas both declined the job before Overton, and outgoing Sen. Bill Cassidy of Louisiana, a physician, has already voiced concerns about her nomination heading into Senate confirmation. Confidence: High on the nomination itself. Medium on the “third choice” detail and Sen. Cassidy’s concerns, which rest on anonymous-official and press accounts rather than a White House statement this run could independently confirm. Sources: What to know about Dr. Heidi Overton, Trump’s pick to lead the FDA, NPR, Trump set to nominate Heidi Overton to be FDA commissioner, STAT News.

21.6 percent: that is the average 2027 individual health insurance premium increase Oregon regulators just approved, with small-group plans rising almost as much. The Oregon Division of Financial Regulation (DFR) finalized 2027 health insurance rates August 18, 2026, approving a 21.6 percent average increase in the individual market and a 15.5 percent average increase in the small-group market, the latter trimmed down from insurers’ original 17 percent request. DFR pointed to the loss of enhanced federal ACA premium subsidies, rising medical costs, and tariff pressure on durable medical equipment and pharmaceuticals as the main drivers, and said the state used its reinsurance program to hold rates lower than they otherwise would have been. Coverage choice is also narrowing: only two carriers will sell statewide, 23 counties will have three insurer choices, and six counties will be down to two. Confidence: High. This run reviewed the Oregon Division of Financial Regulation’s own announcement directly. Sources: Division of Financial Regulation finalizes 2027 health insurance rates, acts to preserve coverage choices statewide, Oregon Division of Financial Regulation.

Round 2: that is which year of Medicare’s drug price negotiation program a federal appeals court just mostly upheld, rejecting Teva Pharmaceuticals’ bid to escape it. The U.S. Court of Appeals for the D.C. Circuit ruled August 18, 2026 in Teva Pharmaceuticals USA v. Kennedy that the Inflation Reduction Act permits CMS to treat Teva’s Austedo and Austedo XR, movement-disorder drugs selected for the negotiation program’s second round, as a single statutory drug, and rejected Teva’s argument that being forced to accept a negotiated price violates the company’s constitutional property rights. The court did hand Teva one narrower opening, reviving its separate challenge to CMS’s “bona fide marketing” standard for when a generic competitor counts against a brand drug’s negotiation eligibility, and sending that piece back to the district court rather than ruling on it directly. The decision keeps intact the negotiated prices Medicare enrollees are counting on from the program’s earlier rounds, while pharmaceutical manufacturers continue fighting the program in multiple circuits. Confidence: High. This run reviewed the D.C. Circuit’s own opinion directly. Sources: Teva Pharmaceuticals USA, Inc. v. Kennedy, No. 25-5425, U.S. Court of Appeals for the D.C. Circuit.

$9 million: that is what three Buffalo-area nursing homes are paying after admitting to two separate years-long Medicaid and Medicare fraud schemes at once. Safire Rehabilitation of Northtowns, Safire Rehabilitation of Southtowns, and Williamsville Suburban, all Erie County, New York skilled nursing facilities, agreed this week to pay $9 million and adopt new compliance procedures to resolve allegations spanning two schemes: billing Medicare and Medicaid from 2015 through 2019 for rehabilitative therapy that was not medically necessary, undocumented, or never provided at all, and separately submitting false data to the New York Department of Health from 2016 through 2020 to inflate the facilities’ Medicaid reimbursement rates. Of the total, $6 million resolves the Medicaid allegations ($3.6 million to New York, $2.4 million to the federal government) and $3 million resolves the Medicare allegations, with the investigation run jointly by the New York Attorney General’s Medicaid Fraud Control Unit and the U.S. Attorney’s Office for the Western District of New York. Confidence: Medium-High. This run reviewed direct local reporting citing the U.S. Attorney’s office; the New York Attorney General’s own press release could not be independently located this run. Sources: Safire nursing homes to pay $9M to resolve fraudulent billing allegations, WKBW Buffalo.

3,329: that is how many times federal prosecutors say one Chicago man called pharmacies pretending to be a doctor, just to get himself and paying customers GLP-1 weight-loss drugs. The U.S. Attorney’s Office for the Southern District of New York, working with the FBI and HHS’s Office of Inspector General, charged Rodney Greer, also known as “Christian Marchand,” in a four-count indictment alleging that between January 2023 and March 2026 he called roughly 261 pharmacies about 3,329 times, using real physicians’ names and license numbers to impersonate them and fraudulently authorize GLP-1 and other prescription medications for people who paid him for the service. Prosecutors say the scheme let those customers redeem hundreds of thousands of dollars in health-plan benefits they were not entitled to, without ever obtaining a legitimate prescription or prior authorization, exploiting a pharmacy-verification gap that has made GLP-1 drugs a growing fraud target as demand and prices climb. Confidence: Medium. This run reviewed press coverage summarizing the FBI field office’s announcement of the charges; direct retrieval of both the Department of Justice’s and the FBI’s own pages returned access errors, a recurring pattern this newsletter has flagged before with justice.gov. Sources: Illinois Man Charged With Scheme To Impersonate Doctors And Make False Statements To Obtain GLP-1 Medications, FBI New York Field Office.