CMS Innovation Project May Bypass Obesity Drug Ban (Maybe), Remote Monitoring Startups Ruin It for Everyone, Elevance Makes Facilities Eat the Cost of Out-of-Network Care

Hey all,

Happy Monday! Healthcare has perfected the art of making legal compliance and clinical benefit completely unrelated concepts. Medicare can't legally cover GLP-1s for obesity—a condition affecting 40% of Americans and costing $170 billion annually—but spent years reimbursing RPM programs that monetized CPT codes with no clinical utility whatsoever. Meanwhile, hospitals and practices are now dedicating resources to enforcing insurers' out-of-network penalties rather than, you know, treating patients. The system isn't broken—it's working exactly as designed, which is to say optimized for billing rather than outcomes.

Enjoy the rundown!

Jacob Brody (Co-Founder & CEO, ZorroRX)

(Cost Curve) Analysis of TrumpRX GLP-1 Deal

The Trump administration has announced a high-profile deal with Eli Lilly and Novo Nordisk to expand Medicare access to GLP-1 drugs for obesity, a condition that affects over 40% of U.S. adults and drives more than $170 billion in annual healthcare costs. The agreement includes over 20 new price points for injectable and upcoming oral GLP-1s, and points to a potential CMS Innovation Center demonstration project as a path forward, though Medicare is still barred by law from covering obesity medications—meaning any permanent coverage expansion would likely require congressional approval. While the move could significantly impact treatment options for the estimated 18 million Medicare beneficiaries with obesity, major questions remain around reimbursement, eligibility, and plan participation: Full Article

(LinkedIn Post by Rik Renard) United Decision Could Mean RPM Business Model Collapse

Rik Renard highlights UnitedHealthcare’s drastic narrowing of RPM coverage—now limited to just heart failure and hypertensive disorders of pregnancy—as a predictable fallout of the abuse he saw firsthand: RPM startups pitching revenue-sharing schemes with providers while ignoring actual clinical utility. He recalls the post-COVID boom where CPT codes became a shortcut to easy money, with companies focused more on monetizing reimbursements than leveraging patient data for real outcomes. In his view, the market got flooded with bad actors chasing billables, making it nearly impossible to separate genuine innovation from exploitation—so now the whole sector is paying the price. Full Post

(HEALTH CARE un-covered) Elevance’s 10% Penalty Policy on Out-of-Network Doctors
Elevance Health plans to impose a 10% reimbursement cut on hospitals and outpatient facilities when out-of-network doctors treat its insured patients, starting January, potentially pushing many independent practices toward collapse. This move—framed as a way to reduce patient costs—mirrors tactics by other insurers like UnitedHealth and Cigna, all seeking to boost profits amid stock pressures by restricting provider networks and burdening hospitals with enforcement responsibilities. If adopted widely, it could hasten the extinction of independent medical practices and disrupt patient access. Full Article