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PAYER CROSS-DRIFT

CMS Transparency in Coverage payer-level rollup, PY2025 vs. PY2026. 307 issuer × plan-year rows. All rates weighted by appeals filed. Rows with zero denominators dropped before rate computation.

307 ISSUERS PY2025 / PY2026 8.1% BH BASELINE

01 Worst-Actor Composite

Composite = (BH share × median multiplier) − (overturn × median multiplier). Higher = worse. Cigna, Aetna, and Molina are the operationally meaningful worst actors — non-trivial volume, elevated BH share, below- or near-median overturn. Health First is a structural outlier (single-state, low absolute volume, explosive growth — see movers).

Rank	Payer	BH Share	vs Median	Internal Overturn	Note
1	Health First	39.9%	4.9×	43.2%	FL only, 481 BH denials, +1,449% YoY
2	Cigna	27.4%	3.4×	40.8%	Highest absolute BH volume in dataset
3	Aetna	21.7%	2.7×	32.1% (0.77×)	Only top-3 below median overturn
4	Molina	12.7%	1.6×	36.3%	Volume monster behind Cigna
5	BCBS	8.8%	1.1×	45.0%	Right at the median

02 Top Movers · PY2025 → PY2026

Health First +1,449% BH denial volume (481 → 7,450), +20pp internal overturn, +60pp BH share. Likely a reclassification or reporting onboarding event more than organic behavior change — caveat.

Oscar −98% BH denial volume (6,333 → 122), −20pp internal overturn, +39pp BH share. Volume collapse with simultaneous share spike suggests deliberate scope change (program exit or definition shift), not real loosening.

BCBS +67% BH denial volume (22,956 → 38,345), external overturn rate +11.4pp. The most material genuine tightening in the dataset.

Molina −50% BH denial volume (172,349 → 87,000) but +18.2pp internal overturn and +30.8pp external overturn. Fewer denials, more reversed on appeal — clean loosening.

Ambetter/Centene +35% BH denial volume but −42.6pp internal overturn. Denying more, sustaining more. A clean tightening signal.

03 Cross-Drift Matrix (Payer × Plan Year)

Per-family aggregate. Sort any column.

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04 YoY Delta · PY2025 → PY2026

Payers with both years reported. Delta columns capture direction; flat industry baseline (median YoY BH denial volume change = −3.5%).

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05 Implication

Yes — this dataset surfaces real cross-payer BH drift worth productizing, but the signal is at the issuer-state cell, not the payer-family rollup. The family view tells a clean directional story; the within-family variance (BCBS issuers spanning 0–28% BH share, Molina spanning 9–26%) is where a precedent-based product earns its keep. Roll up for narrative; sell the cell-level intelligence.

Generated 2026-05-20 · Source: stratum-corpus-data · analyses/payer_*

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