CMS

slash475

[https://www.reddit.com/r/Shortsqueeze/comments/1nubni4/crmdcormedix\_biotech\_potential\_short\_squeeze/?utm\_source=share&utm\_medium=web3x&utm\_name=web3xcss&utm\_term=1&utm\_content=share\_button](https://www.reddit.com/r/Shortsqueeze/comments/1nubni4/crmdcormedix_biotech_potential_short_squeeze/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button) I went into it a little bit a couple months ago and still think it could squeeze, but not from this. I've been in the stock for over 3 years and these numbers are insane and pt should be a lot more, but there was a shelf offering in June right after LDO1 was signed and an acquisition of Melinta. The dark cloud hanging over it right now is CMS TDAPA reimbursement news. CRMD has requested an extension and updated pricing for post TDAPA which will begin next summer. If they get good news, it could seriously take off. Also, real world evidence study results will be released by the end of year. If that comes back as we all hope, showing that it prevents infections at the rate it does, it could pop as well. While I do think we'll see nice movement today, I don't think the true value and squeeze will come until the CMS decision is released.

ContributeAVerse

Copy pasta if you want it The Trump administration is negotiating a deal with weight-loss drugmakers Eli Lilly and Novo Nordisk that would allow the lowest doses of some of their obesity drugs to be sold to consumers at $149 for a month's supply via TrumpRx, according to people familiar with the matter. The deals would also result in Medicare and Medicaid covering the drugs for weight-loss, the people said, which would be a boon to the companies. The discussions are still ongoing but if agreements are finalized, Trump is expected to announce them Thursday morning at the White House, alongside pharmaceutical executives, the people said. The agreement would allow Medicaid coverage for the popular but pricey drugs known as GLP-1s, including bestsellers Wegovy and Zepbound, to treat obesity. And it would require Medicare to cover the drugs for obese people who are also at high risk of other health problems, the people familiar with the matter said. The lowest dose of Novo Nordisk's Wegovy would be offered through TrumpRx at $149, the people said. The starting dose of Lilly's Zepbound would be sold for $299, $50 less than the price that the company currently charges patients buying directly through Lilly's direct-to-consumer website online, according to one of the people. In addition, Lilly would sell the starting dose of its weight-loss pill, orforglipron, for $149 via TrumpRx, if the drug, which is now in testing, is approved by the Food and Drug Administration. Ozempic, the diabetes drug also made by Novo Nordisk that is already covered for many Medicare and Medicaid patients, may also be offered on TrumpRx, according to one of the people, who didn't specify a potential price. As part of the deal negotiations, Lilly is seeking a voucher from the FDA that would speed up review of the company's weight-loss pill, the people said. The company has applied for the voucher, but it wasn't clear if it will be awarded by Thursday. The voucher could potentially be very helpful for Lilly, allowing it to speed up FDA review of its application to just one to two months. Normally, the FDA takes anywhere from 6 to 10 months from accepting a new drug application to complete its review. The potential agreements involve promises by the drugmakers to provide patients with "digital solutions" meant to encourage diet and exercise, people familiar said. Currently, Medicare drug-benefit plans are permitted to cover the weight-loss drugs for nonobesity uses, such as reducing risk of heart attacks or sleep apnea. Few states cover the drugs for weight loss in their Medicaid programs. A spokeswoman for Lilly said the company "is in discussions with the administration to further expand patient access, preserve innovation, and promote affordability of our medicines. We do not have specific details to share at this time." A spokeswoman for Novo Nordisk said the company "is engaged in constructive discussions with the Administration" and wants to make its drugs more affordable. A CMS spokesperson said the president wants to make these products more affordable, and that when a deal is completed, the administration will announce it. Trade publication Endpoints News earlier reported a deal was near. The deal is part of the negotiations the Trump administration kicked off with major drugmakers in July in an attempt to lower U.S. drug costs with a policy known as "most favored nation" pricing. So far Pfizer, AstraZeneca and EMD Serono have announced deals with the administration. Health Secretary Robert F. Kennedy Jr. has made fighting obesity and accompanying chronic diseases one of the primary goals of his Make America Healthy Again agenda. But in the past he has expressed skepticism about GLP-1s and last year criticized legislation to broaden coverage of the drugs, which he said would cost about $3 trillion. Centers for Medicare and Medicaid Services Administrator Mehmet Oz, a heart surgeon, persuaded Kennedy to back the coverage expansion by showing him scientific studies about how the medicines can prevent heart disease and diabetes, and data on the resulting cost savings to the federal government, people familiar with the matter said. President Trump last month said the "fat loss drug," or Novo Nordisk's Ozempic, could be sold to Americans at $150 or "much lower," but Oz quickly stepped in front of him and said the negotiations were still ongoing. Write to Liz Essley Whyte at liz.whyte@wsj.com and Peter Loftus at Peter.Loftus@wsj.com

altonbrushgatherer

Odd because CMS is cutting reimbursements in 2026… doctors are getting the double whammy of inflation and decreased reimbursements per unit work.

Thalesian

> All ACa did was raise taxes and borrowing to give subsidies to being the price down while all the charges went up. Here’s a [research paper](https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.01478) that goes into detail that I’m sure will lead to informed debate. > The most definitive source of information on health spending throughout this period comes from the CMS National Health Expenditure Accounts Team. Exhibit 2 displays per capita and total national health spending with the subtitles of the team’s annual Health Affairs articles since the passage of the ACA superimposed. Collectively, these studies make it clear that yearly spending growth generally has been slow by historical standards since the ACA’s passage. The exceptions are 2014 and 2015 (when coverage expansions and the launch of high-cost drugs that cured hepatitis C drove spending) and 2018 (when private insurance prices climbed). While the growth trends are inconclusive about the degree to which the ACA contributed to lower spending growth rates, they provide no evidence that the ACA accelerated growth

Odd_Winter9070

Lmao this ain’t UNH’s first CMS rodeo, champ. They’ve been eating rule changes and spitting out record cash flow for decades. V28 just weeds out the weak smaller insurers drown, UNH scales. They’ll reprice, tighten coding, and print again by 2026. Same movie, new villains.

Rainyfriedtofu

hahaha you don't know squat about CMS rules or anything about insurance headwinds in 2026 do you? We're looking at bankruptcies here. Go read up on implementation of CMS V28 and how it will be going int o full implementation and how it will normalized and restrain risk scores. The purpose is to prevent companies like UNH and Humana from cooking the book. UNH need to have tighter coding/clinical programs to hold its current MCR which is a 89.9% which is fucking high. Right now inpatient/outpatient is running hot. If you go back and look at UNH's previous earnings, MCR pressure is running higher despite higher rates. Also go looks at CMS start rating-everyone is getting hits and there are less and less 5 stars plan now than before due to CMS v28. Everyone is losing bonus dollars. In short, 2026 winners are plans that controlled utilization, executed on v28 risk adjustment, and managed Stars. UNH doesn't falls into this category. Hell they are eating 89.9% MCR on 67% V28 and 33% V24. And you are telling me they are going to do well when it will be 100% v28? Bro, you clearly don't know anything about healthcare. The only ways UNH is going to pump is if we have people like you who don't understand health insurance core business earnings and pumping up the stock purely on buzz words and meme.

Odd_Winter9070

Yeah, ops income dropped no one’s denying that. But UNH raised full year EPS anyway, meaning management already baked in the pain. 2025 is the reset year before 2026 rate hikes and Medicare Advantage repricing hit. HR1 and new CMS formulas shift revenue up for efficient players like UNH. Short term squeeze, long term margin rebound. That’s how tanks reload, bud. 🚀

rair21

Extensions to the Covid era rules are fully expected to be in the government re-opening bill and a more permanent solution is expected after that. It will be the 3rd time they have been extended. You are correct about the present situation since 10/1, but it is fully expected to be a temporary situation. As of 10/21, CMS began paying certain types of telehealth claims again.

slash475

It wouldn't let me attach it yesterday with the AWS issues. They've requested reconsideration on TDAPA reimbursements after the initial first 2 years. If you want to read their submission to CMS you can download it [Here](https://stkt.co/RcTchwzb)

slash475

Good morning! I've been in CRMD for over 3 years and posted about it 3 weeks ago. That post is [here](https://www.reddit.com/r/Shortsqueeze/comments/1nubni4/crmdcormedix_biotech_potential_short_squeeze/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button) . Just wanted to clarify some things about it. Yes, this is amazing news and shows sales are better than expected even a month ago when they raised guidance the first of September. Defencath utilization is better than expected for the LDO1, which is huge news too. However, the most important news for the stock in the short term is the CMS TDAPA reimbursement decision. If it comes back negative, it would prevent any squeeze whatsoever. If it comes back the way we hope, then we would probably see it. Also, potential short term catalysts (if TDAPA decision is neutral or not as good as expected) would be LDO2 sign on, Real world study results and FDA approval on Rezzayo. Keep in mind, that while the deadline for the TDAPA decision was November 1, that could be delayed due to the government shutdown. I'm not posting these things to dissuade anyone from getting in the stock, just wanting to clarify the picture. CRMD has exceeded sales since last July when they began, but the stock always gets beaten back down. Even with the news this morning, we're still sitting lower than at the beginning of October(and much less than the beginning of September even after raising guidance).

slash475

I purchased May calls last month(which honestly are hurting really bad) and I have had shares for years. It's been a tough few weeks, but there will have to be some news in the next month(ER at the least). The CMS TDAPA decision could be delayed because of the government shutdown, but should still come out before EOY. Real world evidence study results are due by end of year as well. If we have a decent ER, good guidance, and a decent TDAPA decision, I could see lift off. Thanks for the info you share, it's good to see the TA side too.

Icy_Bookkeeper_208

Just fyi. A reduction from $10 to $242 is ~96% reduction. To get this number Divide $10 by $242 and subtract the answer from 100, then multiply that answer by 100 and round to the nearest whole number. If you already knew this, then you are more proficient at Math than the current US CMS Admin, Mehmet.

slash475

No, I appreciate this information. There are a several catalysts that could come the next 6 weeks that force a squeeze, but the stars have to align. Right now I think that the CMS TDAPA decision is the most important, but even that may be delayed due to the government shut down.

Captain_America2021

Not trying to kill the vibe, just adding numbers and where the risk really is. What’s actually on the tape: • Dark-pool footprint: ~79% of recent volume printed $10.00–$10.10 (heavy accumulation zone). Above $11, lit liquidity thins out fast → air pocket if it breaks/holds $11.10. • Gamma setup (UW): • By expiry: near-term (10/17) net gamma negative → chop and stop-hunts; Dec 19 flips positive → dips should get absorbed more easily. • By strike: gamma flip ~$12–$12.3. Dealer hedging is a tailwind after it’s through $12. • OI/flow: Biggest call clusters sit Dec 19 $12–$13; intraday net call premium has been positive, but overall options volume is moderate (stealthy, not mania). • Short interest (latest reads): 16.6M short (22–23% of float). Days-to-cover shakes out ~4–6 depending on which volume window you use. Utilization/borrow are mid-range, not “maxed.” • Trend/technicals: Price living under key MAs, RSI mid-30s to low-40s (weak but basing). The $10.00–$10.10 zone is being defended; first choke point $11.10–$11.35. Cloud/MA confluence and gamma flip line up around $12. • Catalyst path: CMS/TDAPA reimbursement decision window is the real accelerant. That’s the thing that can shove it through $11.10 → $12 and put shorts on skates. Where the squeeze case is solid vs. hype: • Solid: High SI for a mid-float name, tight DP base at $10, thin liquidity above $11, and a clean event (CMS) in view. Dec gamma turns from headwind to tailwind. • Hype: “Squeeze incoming” right now is premature. Without a clean close > $11.10 on rising volume (and ideally >$12), shorts aren’t forced. Borrow/utilization aren’t at panic levels. How I’m framing it (not advice): • Basing/accumulation: Accumulation bids have been parked $10.00–$10.10. If that gives, next checks are $9.80 → $9.20. • Trigger 1: Close above $11.10 = opens the runway to test $11.8–$12.3 (gamma flip). • Trigger 2: Through $12 with volume = where dealer hedging + shorts can add fuel toward $13–$14 into Dec OPEX. • Invalidation: Sustained break below $9.80 = squeeze thesis on hold until the base rebuilds. This is more fundamental long with a squeezable cap table than a guaranteed squeeze today. The setups line up after OPEX and into the CMS decision. Watch $10.00–$10.10 for defense, $11.10 for the first unlock, and $12 for the real ignition. If the catalyst hits and it re-prices above the gamma flip, that’s when shorts have a problem.

zepto

CLOV. CMS ratings coming out. Large shorts 50/50 gamble

slash475

Typically they would have done it by now, so I don't think they will for Q3. They would normally do it up until Q2 when they were in the middle of the Melinta acquisition bidding. The main catalysts now will be CMS decision(Nov. 1 deadline) and Real World Study Results. Q3 ER last year was 10/30 but with the new merger I imagine it'll be later, but within the first couple weeks of November. It looks like this may be more of a November play now, but it's possible some news drops before. Full transparency I have a couple thousand shares I've been purchasing since 08/22 with a cost basis of 6.28 and May 15 2026 $16 calls.

Incognew01

NIH Backing, CPT Momentum, and FDA Fast-Track Potential Are Converging **Bionano Genomics Inc.,** isn’t just knocking on the door anymore, **it’s inside the room**. With NIH now actively using Optical Genome Mapping (OGM) in high-impact research like autism, and Centers for Medicare & Medicaid Services (CMS posting a preliminary decision to reimburse **OGM** under a new Category I CPT code, the platform has officially **crossed from outsider tech to institutional infrastructure**. This isn’t hype, it’s validation.  **NIH doesn’t invite just anyone into its fold**. Their use of **OGM** signals that the science is not only revolutionary, but **essential**. When you combine that with CMS’s reimbursement momentum and a political climate where HHS is being pushed to streamline diagnostics, you get a perfect storm of credibility, urgency, and regulatory opportunity.  **FDA approval**? It’s not here yet, but it’s no longer a long shot. The formalities still need to happen, but the **groundwork is being laid in real time**. OGM is already used in Clinical laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA), operating Laboratory Developed Test (LDT), and if NIH’s autism studies deliver the kind of results early adopters expect, FDA clearance could move fast.  **Bionano Genomics made the club**. It’s one of the boys now. And in this game, that means it’s going to be taken seriously, from reimbursement to regulation to clinical adoption. The **science made the case**. The system is catching up.  What’s changing now is **momentum**. The Centers for Medicare & Medicaid Services (CMS) recently posted a preliminary payment determination for a new Category I CPT code covering **OGM** for constitutional genetic disorders. That’s a major signal that the technology is being recognized as clinically useful and reimbursable, two key steps toward broader adoption. Add to that the NIH’s active use of OGM in autism research, and you’ve **got** **institutional validation at the highest level.**

Incognew01

NIH Backing, CPT Momentum, and FDA Fast-Track Potential Are Converging **Bionano Genomics Inc.,** isn’t just knocking on the door anymore, **it’s inside the room**. With NIH now actively using Optical Genome Mapping (OGM) in high-impact research like autism, and Centers for Medicare & Medicaid Services (CMS posting a preliminary decision to reimburse **OGM** under a new Category I CPT code, the platform has officially **crossed from outsider tech to institutional infrastructure**. This isn’t hype, it’s validation.  **NIH doesn’t invite just anyone into its fold**. Their use of **OGM** signals that the science is not only revolutionary, but **essential**. When you combine that with CMS’s reimbursement momentum and a political climate where HHS is being pushed to streamline diagnostics, you get a perfect storm of credibility, urgency, and regulatory opportunity.  **FDA approval**? It’s not here yet, but it’s no longer a long shot. The formalities still need to happen, but the **groundwork is being laid in real time**. OGM is already used in Clinical laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA), operating Laboratory Developed Test (LDT), and if NIH’s autism studies deliver the kind of results early adopters expect, FDA clearance could move fast.  **Bionano Genomics made the club**. It’s one of the boys now. And in this game, that means it’s going to be taken seriously, from reimbursement to regulation to clinical adoption. The **science made the case**. The system is catching up.  What’s changing now is **momentum**. The Centers for Medicare & Medicaid Services (CMS) recently posted a preliminary payment determination for a new Category I CPT code covering **OGM** for constitutional genetic disorders. That’s a major signal that the technology is being recognized as clinically useful and reimbursable, two key steps toward broader adoption. Add to that the NIH’s active use of OGM in autism research, and you’ve **got** **institutional validation at the highest level.**

Incognew01

NIH Backing, CPT Momentum, and FDA Fast-Track Potential Are Converging **Bionano Genomics Inc.,** isn’t just knocking on the door anymore, **it’s inside the room**. With NIH now actively using Optical Genome Mapping (OGM) in high-impact research like autism, and Centers for Medicare & Medicaid Services (CMS posting a preliminary decision to reimburse **OGM** under a new Category I CPT code, the platform has officially **crossed from outsider tech to institutional infrastructure**. This isn’t hype, it’s validation.   **NIH doesn’t invite just anyone into its fold**. Their use of **OGM** signals that the science is not only revolutionary, but **essential**. When you combine that with CMS’s reimbursement momentum and a political climate where HHS is being pushed to streamline diagnostics, you get a perfect storm of credibility, urgency, and regulatory opportunity.  **FDA approval**? It’s not here yet, but it’s no longer a long shot. The formalities still need to happen, but the **groundwork is being laid in real time**. OGM is already used in Clinical laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA), operating Laboratory Developed Test (LDT), and if NIH’s autism studies deliver the kind of results early adopters expect, FDA clearance could move fast.  **Bionano Genomics made the club**. It’s one of the boys now. And in this game, that means it’s going to be taken seriously, from reimbursement to regulation to clinical adoption. The **science made the case**. The system is catching up.  What’s changing now is **momentum**. The Centers for Medicare & Medicaid Services (CMS) recently posted a preliminary payment determination for a new Category I CPT code covering **OGM** for constitutional genetic disorders. That’s a major signal that the technology is being recognized as clinically useful and reimbursable, two key steps toward broader adoption. Add to that the NIH’s active use of OGM in autism research, and you’ve **got** **institutional validation at the highest level.**

ElisabethMager56

The risk adjustment math alone makes this a no-brainer for payers, and once CMS FFS coverage comes through it could be explosive. UNH moving first just sets the stage.. others won’t want to get left behind.

slash475

I mentioned 9 potential catalysts in the next 9-12 months. The most immediate ones are unaudited earnings the first of October, CMS TDAPA decision deadline is 11/1 and Real World Evidence study results by EOY.

Some-Rent-7742

All you folks interested in TLRY: READ THIS! Everyone focuses on state dispensaries or adult-use legalization. The bigger catalyst is federal: DEA rescheduling to Schedule III → kills the 280E tax stranglehold, improves cash flow for operators, and makes capital easier to raise. FDA-approved cannabinoid drugs → potentially reimbursed by Medicare/Medicaid. CMS already covers FDA-approved cannabinoid meds like Epidiolex (CBD) and dronabinol (THC). That’s a real healthcare market, not just dispensary sales. So I’m aiming for exposure where those two currents overlap: pharma-grade cannabinoids, ancillary infrastructure, and real-estate cash flow.- My current holdings Zynerba (via Harmony Biosciences) – Transdermal CBD therapies for CNS disorders. Backed by Harmony’s resources, so more likely to get FDA approval and payer coverage than standalone biotech. Tilray (TLRY) – Major global cannabis operator. Broader exposure across medical, adult-use, and consumer packaged goods. Innovative Industrial Properties (IIPR) – This is my favorite “picks-and-shovels” play. A cannabis-focused REIT that buys specialized cultivation/processing facilities and leases them to state-licensed operators. They collect rent (many leases are triple-net), and rescheduling → 280E relief → tenants have stronger balance sheets → lower credit risk for IIPR. It’s essentially a way to get steady cash flow and dividends from the cannabis boom without plant-touching exposure. --- What I’m hunting next I want more U.S. pharma/ancillary exposure that will benefit from: Schedule III rescheduling (banking, taxes). FDA-approved cannabinoid drugs being covered under Medicaid/Medicare. Non-plant touching businesses (labs, packaging, compliance, logistics). Names on my radar: Green Thumb Industries (GTBIF) – Large MSO in the U.S. KushCo (KSHB) – Ancillary packaging/compliance. Other U.S. biotechs with cannabinoid pipelines. Raw CBD/hemp oil ≠ reimbursable. FDA-approved cannabinoid drugs = reimbursable. That’s where Zynerba/Harmony fits. Global names like Tilray = diversification. IIPR = steady cash flow, dividends, and less regulatory exposure. Rescheduling + CMS coverage would light up this space, but even before that, IIPR gives real fundamentals that most cannabis tickers lack.

Some-Rent-7742

My current holdings Zynerba (via Harmony Biosciences) – Transdermal CBD therapies for CNS disorders. Backed by Harmony’s resources, so more likely to get FDA approval and payer coverage than standalone biotech. Tilray (TLRY) – Major global cannabis operator. Broader exposure across medical, adult-use, and consumer packaged goods. Innovative Industrial Properties (IIPR) – This is my favorite “picks-and-shovels” play. A cannabis-focused REIT that buys specialized cultivation/processing facilities and leases them to state-licensed operators. They collect rent (many leases are triple-net), and rescheduling → 280E relief → tenants have stronger balance sheets → lower credit risk for IIPR. It’s essentially a way to get steady cash flow and dividends from the cannabis boom without plant-touching exposure. What I’m hunting next I want more U.S. pharma/ancillary exposure that will benefit from: Schedule III rescheduling (banking, taxes). FDA-approved cannabinoid drugs being covered under Medicaid/Medicare. Non-plant touching businesses (labs, packaging, compliance, logistics). Names on my radar: Green Thumb Industries (GTBIF) – Large MSO in the U.S. KushCo (KSHB) – Ancillary packaging/compliance. Other U.S. biotechs with cannabinoid pipelines. Raw CBD/hemp oil ≠ reimbursable. FDA-approved cannabinoid drugs = reimbursable. That’s where Zynerba/Harmony fits. Global names like Tilray = diversification. IIPR = steady cash flow, dividends, and less regulatory exposure. Rescheduling + CMS coverage would light up this space, but even before that, IIPR gives real fundamentals that most cannabis tickers lack.

Some-Rent-7742

- My current holdings Zynerba (via Harmony Biosciences) – Transdermal CBD therapies for CNS disorders. Backed by Harmony’s resources, so more likely to get FDA approval and payer coverage than standalone biotech. Tilray (TLRY) – Major global cannabis operator. Broader exposure across medical, adult-use, and consumer packaged goods. Innovative Industrial Properties (IIPR) – This is my favorite “picks-and-shovels” play. A cannabis-focused REIT that buys specialized cultivation/processing facilities and leases them to state-licensed operators. They collect rent (many leases are triple-net), and rescheduling → 280E relief → tenants have stronger balance sheets → lower credit risk for IIPR. It’s essentially a way to get steady cash flow and dividends from the cannabis boom without plant-touching exposure. --- What I’m hunting next I want more U.S. pharma/ancillary exposure that will benefit from: Schedule III rescheduling (banking, taxes). FDA-approved cannabinoid drugs being covered under Medicaid/Medicare. Non-plant touching businesses (labs, packaging, compliance, logistics). Names on my radar: Green Thumb Industries (GTBIF) – Large MSO in the U.S. KushCo (KSHB) – Ancillary packaging/compliance. Other U.S. biotechs with cannabinoid pipelines. Raw CBD/hemp oil ≠ reimbursable. FDA-approved cannabinoid drugs = reimbursable. That’s where Zynerba/Harmony fits. Global names like Tilray = diversification. IIPR = steady cash flow, dividends, and less regulatory exposure. Rescheduling + CMS coverage would light up this space, but even before that, IIPR gives real fundamentals that most cannabis tickers lack.

Some-Rent-7742

Everyone focuses on state dispensaries or adult-use legalization. The bigger catalyst is federal: DEA rescheduling to Schedule III → kills the 280E tax stranglehold, improves cash flow for operators, and makes capital easier to raise. FDA-approved cannabinoid drugs → potentially reimbursed by Medicare/Medicaid. CMS already covers FDA-approved cannabinoid meds like Epidiolex (CBD) and dronabinol (THC). That’s a real healthcare market, not just dispensary sales. So I’m aiming for exposure where those two currents overlap: pharma-grade cannabinoids, ancillary infrastructure, and real-estate cash flow.

flat-waffles

Optum was down because they were growing topline and in the middle of their 3 year transition. From the earnings call • First, growth in certain markets where there were meaningful plan exits. These new patients had not been engaged by their prior plans for most of last year and we are seeing revenues associated with the patient profiles meaningfully below expected and normal levels. This is very addressable. • Second, the ongoing execution to the new CMS risk model, while complicated given the multi-year phase-in, has not been to our operational standards. Transitioning to a new model and concurrently running two distinct versions has been more operationally complex than anticipated. But no question, we need to execute better, and we will.

Natural_Flamingo9365

* 2024 * The Centers for Medicare & Medicaid Services (“CMS”) finalized the 2024 Home Health Rule which includes exoskeletons in the Medicare brace benefit category, reimbursed by Medicare on a lump-sum basis. The Home Health Rule went into effect on January 1, 2024. * CMS revised its April 2024 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (“DMEPOS”) Fee Schedule to include a final lump-sum Medicare payment rate for personal exoskeletons. * The MACs have begun approving previously submitted Lifeward claims for payment. * The CMS Home Health Rule and Medicare Pricing achieved by Lifeward is now fully functional with widespread approvals and the beginning of payments from our 2023 and first-half 2024 submissions. With the experience of access for Medicare beneficiaries, physicians are now able to actively write prescriptions with confidence that on-label SCI individuals have access to this innovative walking and stair climbing technology. * In June, Lifeward successfully launched the latest generation of Differential Air Pressure Anti-Gravity Technology with its new NEO product line. The NEO provides features that are aligned for independent clinics seeking to offer this advanced technology. * In June, Lifeward completed its FDA submission for its 7th generation ReWalk design which will further enhance use of the system in all aspects of daily life and further establish Lifeward as the most experienced personal exoskeleton company in the world. Lifeward initiated actions to further streamline its U.S. operations including closing two U.S. facilities to complete the integration of AlterG. The actions are expected to save the Company approximately $3 million in operating expenses and improve gross margins by approximately two percentage points when the full impact is achieved. * Lifeward began selling the AlterG family of products through its German sales organization which the Company expects will result in revenue growth from a more focused sales effort and higher margins with little incremental investment by utilizing its existing sales and support infrastructure in Germany. * Lifeward executed a successful launch of the AlterG NEO which was engineered with a new design to allow a lower price point to make the technology more accessible to a broader range of customers. Since the introduction of the NEO at the end of June, Lifeward has generated orders for approximately 40 units as the NEO is quickly becoming a growth driver for the AlterG product line. 2025: Achieved FDA clearance and subsequent U.S. launch in April 2025 for the ReWalk 7, the latest innovation in the ReWalk pipeline, with over 20 ReWalk 7 units installed to date with overwhelmingly positive feedback from customers. Expanded and advanced the pipeline of qualified leads for the ReWalk and achieved the highest quarterly total of ReWalk units placed for Medicare beneficiaries since fee schedule established in April 2024. Continued expansion of U.S. payer base for the ReWalk Personal Exoskeleton. On the Medicare front, a ruling by an Administrative Law Judge established a legal basis for medical necessity by affirming that the ReWalk Personal Exoskeleton is “reasonable and necessary” for a Medicare beneficiary. Additionally, the partnership with CorLife, a division of NuMotion, has already facilitated and accelerated processing for workers compensation claims, with the first paid claim. [Quarterly Results | Lifeward Ltd.](https://ir.golifeward.com/financial-information/quarterly-results)

Natural_Flamingo9365

2022: Placed on June 8th CMS agenda of the Biannual Healthcare Common Procedure Coding System (HCPCS) meeting that includes benefit category determination for the first time under the new DEMPOS rules. * ReWalk has increased resources and presence in VA Polytrauma/TBI Care Systems as well as a process to expand training through the VA’s designated Community Based Outpatient Clinic network. * In April 2022, the Company joined the Human Robot Interaction Consortium, part of the Israel Innovation Authority MAGNET incentive program, where it will collaborate with several universities to develop advanced technologies aimed at improving the human-exoskeleton interaction. * ReWalk advanced its commercial readiness and finalized plans for expanded Medicare patient access following the satisfactory resolution of the first submitted claim; 2023: In March 2023, the ReWalk Personal Exoskeleton technology received 510(k) clearance from the U.S. Food and Drug Administration (“FDA”) for use on stairs and curbs, making it the only personal exoskeleton to receive FDA clearance for this indication.  * Closing of ReWalk’s acquisition of AlterG, Inc. (“AlterG”), which adds significant scale to the annual revenue base of ReWalk and AlterG’s innovative Anti-Gravity technology to the Company’s portfolio of rehabilitation solutions that facilitate mobility and wellness in rehabilitation and daily life. * Active pace of Medicare claim submission activity during Q3’23, better positioning ReWalk for reimbursement eligibility of exoskeletons by Medicare once payments are underway. subsequent to the end of Q3’23, the Centers for Medicare & Medicaid Services (“CMS”) finalized the 2024 Home Health Rule which establishes the inclusion of exoskeletons in the Medicare brace benefit category, reimbursed by Medicare on a lump-sum basis, and subsequently proposed the preliminary reimbursement level for the ReWalk Personal Exoskeleton.

Natural_Flamingo9365

2019 The ReStore exo-suit for stroke rehabilitation received FDA & CE clearances for sale to rehabilitation clinics in the United States and within the European Union * 2020 Finalized agreements with key German payors for the supply of ReWalk Personal 6.0 to qualified patients; * Amended our research collaboration agreement with Harvard to focus on tele-health solutions and extend the term through March 2023; * Entering upper and lower extremity products, offering hand, leg, arm and balance systems with MediTouch * Adding functional electrical stimulation cycle for home and rehab therapy with Myolyn; and * The Centers for Medicare and Medicaid Services ("CMS") issued Healthcare Common Procedure Coding System ("HCPCS") Level II Code K1007 in response to the Company's application. This decision, which will be effective on October 1, 2020, establishes the first such code for exoskeletons. * Received Medicare Provider certification from the Centers for Medicare & Medicaid Services ("CMS"); * Completed additional contract with a German payor * Continued CMS progress made with issuance of HCPCS Level II Code for ReWalk Exoskeleton enabling an upcoming application for coverage 2021: The Company entered into a contract with BKK Mobile Oil health insurance to supply ReWalk’s Personal 6.0 System to eligible persons in Germany; Additional five BKK partners have joined the operating contract in Germany * Received FDA breakthrough device designation for ReBoot, a soft exoskeleton for stroke home and community use

Simple-Software3

As you mentioned in another post, timing is what matters. I personally believe it's going to take YEARS before this trickles and impacts to large players (PACS is a large player, it is top 3 in size easily). Their bread-and-butter, with a proven track record, is acquiring bleeding facilities that are losing money and turning them around into money making machines. This is great for pacs in the near term, sucking up these small players and turning them around because they have the playbook down to a science and the resources to do so. Even just recently: [https://www.mcknights.com/news/skilled-nursing-owner-buckeye-chai-files-for-bankruptcy-months-after-selling-facilities-to-pacs/](https://www.mcknights.com/news/skilled-nursing-owner-buckeye-chai-files-for-bankruptcy-months-after-selling-facilities-to-pacs/) Please don't compare assisted living to skilled nursing. Come on. Am I worried about CMS and cuts to midcare/medicaid due to the current administration? Yes. In any case they are still completely undervalued at the current estimated financials and growth. Could some of this impact share price and gains in the very long term (years+), sure, but they are still printing money at this point and will continue to do so right now. I just don't think you can realistically open a bearish long position right now.

easye_was_murdered

My cost basis is $307, man. They affirmed their guidance for the rest of 2025 and their CMS ratings were not as bad as feared so they will be getting that extra money from Uncle Sam for caring for all those Medicare Advantage customers. The industry as a whole plans to raise medical insurance premiums by anywhere between 20% to 30% next year. Stephen Hemsley is back at the helm, in the office multiple days a week at the office in Minnesota (unlike Witty, who frequently worked remotely) working hard to bring the company back on track. Of course I do not deny that the company has more to prove down the road and a reversal back to price levels seen a few months ago is totally possible. But in a market devoid of real turnaround opportunities, UNH is one of the few ones.

easye_was_murdered

Not really. A lot of political progressives want a single-payer system, e.g., CMS being the only entity paying claims. Under such a system, UNH basically would stop existing except only as a private supplementary insurer, and their business would shrink dramatically on the insurance side. They got their clinical side though with Optum. Many other countries have such systems, with supplementary private medical insurance for those who have special needs or want something better than a public hospital.

easye_was_murdered

I bought back my calls today at a slight loss. Going to let it run, has very strong momentum right now. A bit overbought based on technicals, but they affirmed guidance for the rest of 2025 and their CMS ratings are still mostly intact. I expect decent EPS growth in 2026, Hemsley's definitely planning to underpromise and overdeliver.

easye_was_murdered

Sentiment was extremely negative for months now. But it’s turned and it’s now much safer to buy IMO. UNH has reaffirmed its 2025 forecast, got decent ratings from CMS… I’m looking for $520 at year end.

timeforachangee

“Centers for Medicare & Medicaid Services (CMS) Medicare Advantage star ratings for Star Year 2026 / Payment Year 2027; ~78% of its membership in 4 star or higher plans”

timeforachangee

“Centers for Medicare & Medicaid Services (CMS) Medicare Advantage star ratings for Star Year 2026 / Payment Year 2027; ~78% of its membership in 4 star or higher plans”

timeforachangee

“Centers for Medicare & Medicaid Services (CMS) Medicare Advantage star ratings for Star Year 2026 / Payment Year 2027; ~78% of its membership in 4 star or higher plans”

Prestigious_Ape

Be careful. CMS isn't done with the audit.

NotMe357

"TACO administration tiptoes into testing prior authorization in traditional Medicare" "How it works CMS will contract with private companies to deploy “enhanced technologies, including artificial intelligence (AI)” to conduct the authorization reviews. It won’t apply to in-patient or emergency services or treatments “that would pose a substantial risk to patients if significantly delayed,” according to a CMS press release. Specific services that will require prior authorization are skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy." ---- Yahoo Finance Lmao, that sounds just like how UNH is doing.

SeraphimSphynx

Th government does not charge itself a Medicaid or Medicare "insurance rate" just so you know. Not how that works at all. The government only pays the cost of the healthcare utilized against the plan for Medicare/Medicaid. The centers for Medicare and Medicaid science (CMS) set the rates based on BLS cost data and census information. Now some states did institute privatized Medicaid plans where they pay a private company to manage their Medicaid for them and essentially pay a health insurance rate in those cases but that's the exception not the norm. Medicare advantage is similar, private companies convincing granny that private is better and taking her off Medicare. But then she is paying premiums to Aetna/bcbs for essentially a privatized health plan for seniors cutting the government out if it.

gizamo

Lmfoa. Figma didn't supercede Adobe for web design. Adobe hasn't had a good tool for web design since Dreamweaver and Flash, which both shit the bed more than a decade ago. 99.9% of web devs had already completed abandoned Adobe for design tooling long before Figma gained any popularity. Then, Adobe tried to copy Figma with their XD product, and then they tried to buy Figma, which fell thru. Adobe pushes Adobe Experience Manager (AEM), but that's not a design tool. It's a CMS and DAM...and an absurdly expensive one that's pretty mediocre at what it does. They couldn't even integrate it well with Magento, which was probably the most flexible e-commerce platform for a decade or so. Tldr: Adobe has always sucked at everything relevant to web design and development.

easye_was_murdered

The entire industry got crushed by both people seeking more care and CMS pulling back on a billing loophole (e.g., V28). Utilization of benefits is up, and UNH got crushed on both ends because they both have an insurance arm and a clinical arm. If you think the industry can adapt to these changes and resume earnings growth, buy the stock. Otherwise, this whole thing is a bet on whether you think margins will recover or not.

Critical-Falcon-8004

**Centers for Medicare & Medicaid Services** CMS— the U.S. federal agency that oversees Medicare, Medicaid, and health insurance standards. Will *pilot Medicare and Medicaid coverage* for GLP-1 weight-loss drugs like Wegovy and Ozempic (Novo Nordisk $NOVO) [https://www.reuters.com/business/healthcare-pharmaceuticals/us-plans-medicare-medicaid-coverage-weight-loss-drugs-washington-post-reports-2025-08-01](https://www.reuters.com/business/healthcare-pharmaceuticals/us-plans-medicare-medicaid-coverage-weight-loss-drugs-washington-post-reports-2025-08-01)

beargambogambo

I’m not playing Figma but for those who are, they just recently bought Payload CMS which is an insanely good headless CMS for Next.js. I feel in love with it a few months ago because of its capabilities and developer experience and everyday I find more and more to love about it. Figma is clearly making the right moves.

Pitiful-Recover-3747

I think you’re seriously underestimating the risk with UNH and their provider side. Optum is a 5 alarm poorly integrated shit show that’s the nations largest employer of physicians and only been looked over because of the absolute crazy level of Medicare & Medicaid payments that get handed their way. The federal and state investigations are gonna screw all that sideways. That government sponsored rectal exam is also going to wreck all the contracted services optum engages in where they try to subcontract less profitable operations of hospitals. Well if the hospital is worried about getting caught in the CMS cross hairs, they’ll boot the Optum contractors out at the first renewal. Btw, I’m a consultant working in health plan compliance that’s worked for both plans and regulators. My advice is sell that down any day you’re up. Don’t leave more than 10% of your portfolio riding on that bet because you need a lot of miracles.

Rare-ish_Birb

Fwiw, nobody is buying this as long as medicare and medicaid spending is in the media and until CMS reimbursement rates and insurance premiums for next year are known. There is no upside.....big money will find somewhere else to go.

Ill-Chemical-348

Watching YOU. They are meeting with HHS and CMS today. Some contracts will be made but no way to tell with who. If Congress starts buying their stock we'll know.

newans11

TL;DR • Gov’t green light: The July 2025 U.S. AI Action Plan puts medical-AI adoption on fast-forward—regulatory sandboxes, NIST benchmarks, reimbursement pathways, data-sharing, and a federal procurement toolbox. • Tempus is pre-positioned: It already has FDA-cleared diagnostics, a multi-modal data engine, EHR integrations, and live hospital deployments—the very capabilities the Plan now prioritizes. • First-mover advantage: Tempus can plug straight into the new sandboxes, supply evidence for NIST metrics and CMS reimbursement, leverage expanded public datasets, and qualify for streamlined federal purchasing. • Net effect: Policy tailwind + unmatched readiness = a decade-scale boost for Tempus AI. Long $TEM.

CampSea1101

They have earnings soon. They are expected to turn profitable, and there have been some subdomain discoveries that might have leaked potential partnerships with some big names in the healthcare industry, such as Humana. Sure it's mostly speculation for now, but the last time this thing rallied from 2.6 to 3.6 in a matter of days, the CMS star rating got leaked a few days before it became public knowledge. I guess the trader here is banking on the fact that these rumors will not only be made material at the next ER, but that there will also be their first profitable quarter, which will send it to attempt to test the recent 52 weeks high at the very least.

gopoohgo

Dude, UNH is a minefield. Their costs are shooting up because of the shitty pub they got re; their denial rate. Their Medicaid/Obamacare plans are going to be taking a hit as the state matching formulation was changed in the BBB There is a GIANT regulatory overhang with the FBI and CMS looking at their upcoding scheme to get extra billions from their Medicare Advantage products.

IJesusChrist

Well, CMS isn't going to cover skin replacements so their whole pipeline is fked. This is good news, obviously. 

Latter-Variety-8455

I think its a reasonable long-term buy. silly to buy options now imo too hard to time. I really believe that even if UNH loses all of their employer&individual, they can still be a 400 stock. Medicare and Medicaid cuts will definitely hurt but thats just how the damn CMS is theyll recover plus thats a Macro issue that all the insurers gotta deal with.

Odd_Perception_283

What makes you so sure it’s a nothing burger? Legacy insurers defrauding CMS out of billions is a stated and known fact. By how much is the question. But they’ll probably pay 3% of the money they made in fines and be on their way. The corruption is just so sweet!

Odd_Perception_283

You think none of them upcode? Particularly UNH? Despite CMS saying billions haven’t been taken fraudulently through upcoding over the years? Is the criminal probe just a witch-hunt?

scooterfest

I really liked the leap play when it first fell, but I’m holding off cause not quite comfortable with a couple of things. My concerns are around their Medicare sector as a whole. They announced that they’re not paying broker commissions anymore for certain products which will affect their growth. Plus their MCR isn’t conducive to profit. Finally, I think they’re going to get nailed by recoupment requests from CMS for the overpayments they received. CMS just launched an initiative to crack down and is increasing their audit staff from 40 to 2000! In an effort to clear the backlog from 2018-24 and increase the number of cases that they audit. So basically part of their reported revenue for those years will go down depending on how they frame it. How much it goes down who knows. Historically CMS has been known to overpay 5-8% that they know about but with 2000 auditors instead of 40 I imagine it will go up. I know Medicare isn’t UNH’s only revenue source, but it’s roughly 25% of total revenue for them. I’m kinda waiting to see what they do between now and September. Sept because that’s when they show their 2026 Medicare plan info and we will learn if they’re exciting markets, if there’s degradation of benefits, or not paying brokers. All this to say I really like a long call, but might wait until they have more bad news on the Medicare side this summer and then I’ll buy that dip.

Odd_Perception_283

The healthcare landscape isn’t what it used to be. These companies valuations are being cut in half for a reason and it’s mostly because of structural regulatory reasons. They are having much difficult pivoting in response to CMS value based care push in the form of V28z And the DOJ investigation will absolutely find fraud if they are really actually looking for it. If I were you I’d make an effort to understand what CMS V28 is and how these companies are adapting to it. And how their business models are starting to cause much higher utilization. Because, you know, denying claims all the time just makes health problems worse which cost much more money later.

IwearWinosfromZodys

Damn bro, I would’ve picked Humana over UNH. Humana is making good moves for the future. That’s why their MCR was lower 1st quarter compared to 4th quarter. United better start thinking of changes to how they operate or their going to get left behind. CMS isn’t playing around with these companies that create bogus risk assessments for increased payments anymore.

Witty_Leadership_967

I know no ones going to read this but oh well here it goes: Ok so Republicans passed the “One big beautiful bill” Democrats are freaking out and spreading misinformation and lies. Republicans don’t know what to believe I took it upon myself to read both the pre-senate and post-senate bills So let’s review Medicare and Medicaid. 1: THERE ARE NO CUTS TO MEDICARE AT ALL. There is one adjustment within the bill to redirect a portion of medicare funds to implementing an AI system To assist with claims. If you have never seen the backend of Medicare this could go either way. As it stands today alone, i had to Issue $240k in refunds to medicare for incorrect payments. These should have never been paid by medicare and needed 3rd party intervention. So for those saying “there’s no waste” there is most definitely waste. 2: Medicaid: the rumor “17 million people will lose healthcare”. THIS IS A LIE. It is a bold faced lie that doesn exist. The funding was decreased due to removing illegal aliens from medicaid. Every disabled, elderly, low income non-able-bodied person will continue to receive their Medicaid Benefits 3: Rumor: Medicaid is being blocked for disabled by implementing 80 hour per MONTH work requirement. Also not true. This is strictly for able-bodied adults and those without children! Only 20-26% of those on welfare actually work or claim income 4: Rooting out medicaid fraud. True. Medicaid fraud exists and it is at alarming levels. You can go on almost any WIC or MCD facebook groups and read how people are defrauding the government. Not claiming the correct income, falsifying documents, claiming single when married ect. This is for your own eyes. On my end i deal with denials of expired medicaid id’s people who are already dead and more 5: Rumor: People will die from this bill. Absolute joke of a statement. This is a fear mongering statement to scare you into thinking this is a bad bill. 6: tax decreases for the rich. I know you've all seen the graphs showing the bill effecting low income and moving it to the rich. This is not true. That graph is equating the cost of Medicaid supplement for those who lose medicaid where, most, will not. As far as other specific tax breaks - thats not what I am here for, I'm not an accountant or a forensic accountant so I cannot speak to these. Just medicare and medicaid. 7: children will lose their healthcare. Also not true. It’s just not. A child's medicaid is connected to the parents income but the other requirements are not associated. I just cant listen to the lies anymore about things people dont understand when my job is to read and decipher Medicare and Medicaid guidelines and CMS policies. So do with this as you will but please stop spreading the misinformation the figure heads are giving you. If you believe I am wrong about any of these things, I invite you to read the bill and send me the text. It's always possible I may have missed something and if I did I am more then willing to re-review the language and see it. However sources such as Americanprogress. org, which utilizes sources such as the CBO and CHIP their statements are based on speculation NOT hard written fact in the bill, for example their "17 million people will lose healthcare" is actually not even based around Medicaid, its based on the POSSIBILITY (pure speculation) of hospital closures made with EXTREMELY small amount of data. I request that anyone who challenges these points, to provide language DIRECTLY from the bill.

Repulsive-Sundae-361

Totally fair take. Centene is basically the poster child for Medicaid and Marketplace exposure. Huge volumes, razor-thin margins, and zero room for pricing error. If CMS tweaks the rules or a state's rate review committee sneezes, EPS can implode overnight. Elevance, Humana, and UNH might not be as 'cheap' optically, but you're paying for predictability, margin stability, and less political whiplash.

Easytripsy

I did something similar at your age, and the profits paid a chunk of pharmacy school for me. I bought a company called Consumer Power, now CMS energy. It was a utility power company in MI that was trading at a couple dollars a share because it had problems with its nuclear reactors that it was in the process of fixing. It was also not going to go out of business because it was a government run company, but also not going to skyrocket high either. We had a contest in high school over who had the best stock. We voted, my idea got 2nd, First place was Chrysler getting turned around by Lee Iacocca. Excellent choice. But a classmate took all of our choices home to his dad, who was in the business, and told me his dad liked my idea, and encouraged me to actually invest. My father then helped me open a brokerage account and I put my McDonald’s paycheck in. About $300 in 1984.

Virtual_Seaweed7130

There was some potentially PII in the screenshots I provided. It was a UNH long thesis sub 300/share. I work for a risk adjustment validator for medicare advantage plans, the exact area they're being audited in. The thesis was that the audits CMS performs on these providers is ridiculously extensive. If anything happened, it would've been CMS's fault for not flagging it. Coding in general is a subjective task. Highly doubt that there was widespread fraud at UNH but entirely plauseable that they had some questionable coding.

EnragedMoose

I built this in two weeks for my company using off the shelf components. It reviewed several years of contacts (hundreds) and added relevant summaries to our CMS in a few hours. More accurate than our manual reviews.

Definitely_Not_Bots

This shit is the biggest argument against privatizing government agencies or departments like Medicare or NASA or USPS. Imagine USPS was private and the president decided to just end contracts with USPS and go with FedEx or something just because he got mad at the USPS director. Or " Sorry, Medicare won't pay for your insulin because the President didn't like the CMS director's tweet this morning, so now they have no funds. *Shrug.* "

Cultural-Ad678

Yea UNH definitely doesn’t have an ongoing investigation into Medicare fraud and their business model definitely wouldn’t implode if if CMS locked them out for 3 years

AnxietySmart

InsureTech is the future of preventative care! Not yo mention all the CMS changes, which is hitting the bottom line on these dinosaur companies… Money is slowly and quietly flocking to these to be Sleeping future giants like $CLOV $OSCR

PlandomeProwler

IMO more upside, great MCR% ,, 4 STARs from CMS ( better then Humana 3.5 who is their main competition for MA in the few states Clov is in) Clov is only in 5 states Georgia, New Jersey, Pennsylvania, South Carolina, and Texas. So a tremendous amount of room to go + last quarter they only lost 1 million dollars have 390 mill in cash and first true profitable quarter is expected in August which i feel will finally be enough to break it free from this range.

Rare-ish_Bird

New UNH CRO essentially saying they'll build higher margins into their 2026 care submission procing to CMS, but provide the outlook in July earnings meeting.

johnnash3

New CEO was CEO from 2007-2016 so he knows exactly how to make Wall Street and politicians at CMS happy

Strange_Ad6819

I agree that United Health will eventually find it's footing and grow from here especially being down over 50% from highs but they need to get past CMS audits first.  If CMS finds fraudulent billing/upcoding that shit is gonna tank (along w HUM).  You might be better off selling puts on a few solid plays once a month and make 15-25% on your money.  That beats any savings acct.

Ok_Spread_4253

This is not as simple a formula as "healthcare must exist therefore number go back up." A substantial portion of revenue for heath insurance companies comes from CMS and if you had a government that gutted that agency or an administration that threatened to cut costs by investigating insurance companies involved in Medicare advantage, your investment would be a significant risk. And yes, that is exactly what Trump is doing. Might I recommend backing out now and minimizing your loss?

knucklehead27

Those MLR requirements are true of their insurance business, but UNH is able to profit at a much higher rate on the provider side of things (Optum) and the PBM side of things (OptumRx). Furthermore, MLR is equal to claims as a % of premium, and ignores other expenses (admin, overhead, etc.) No health insurer profits 20% on their insurance business. I work in this space, that commonly spread chart about UHC’s denial rates is misleading at best. We do not see a reduction in claims or premium with UHC that is commensurate with a denial rate that high. The real way they were (allegedly) gaming the system is on their Medicare Advantage business. They were upcoding claims, forcing their population to appear riskier, and therefore letting them receive more in reimbursements from CMS than they would otherwise be entitled to.

AppropriateGoat7039

Despite the obvious issues with lying to your wife and gambling your entire net worth on UNH, I think you will make money with the appropriate time horizon. The stock has been overly punished due to short-term headwinds like CMS audits, higher medical costs, and leadership shakeups. These are real issues, but they don’t fundamentally break the business model of a company with decades of operational excellence, scale, and profitability. UNH is trading at valuation levels not seen in over a decade, despite still generating billions in free cash flow and maintaining market leadership in both insurance (UnitedHealthcare) and services (Optum). The regulatory risk and margin pressures are likely cyclical, not structural. While 2025 may be rocky, by 2026–2027 many of these issues will likely be resolved or absorbed into the business model. History shows that buying best-in-class companies during sentiment lows (e.g., JPMorgan in the 2011 banking crackdown or Apple in 2013) often leads to strong long-term outperformance. I didn't lie to my wife and gamble with our life savings, but I am a buyer of UNH and plan on holding for several years. I have seen much worse plays on this sub. Good luck OP, with both your position and your marriage.

OG24_Jack_Bauer

Down 10 percent. Lots going on in healthcare stocks right now, with UNH pulling guidance, many CMS risk adjustment audits, OIG investigations, higher than expected trends it could be choppy for a while. Long term 3-5 years probably a good investment, over the next year unpredictable where UNH is going. If you get a bounce I would get out. You should also discuss now with your wife, and get that straightened out.

Silent_Apricot8381

update on UNH, bullish I think? "We welcome CMS’s announcement to audit every Medicare Advantage plan each year, a policy UnitedHealth Group has long publicly advocated for to strengthen program oversight. We look forward to working with CMS to develop an accurate methodology and appropriately use advanced technology to greatly enhance the auditing process. We share in CMS’s commitment to strengthening program integrity efforts and ensuring Medicare Advantage beneficiaries have access to high-value, affordable care."

theWesternReserve

You do know he’s the head of CMS right

Me-Regarded

Just that CMS news, all insurers got punched. Its not a big deal, they should all quickly recover. Everyone shoots first, thinks later

STG2010

CMS audits will be speeding up.

cutiesarustimes2

CMS has rolled out an expanded Medicare Advantage audit plan. They're now set to review all eligible contracts, recover past overpayments, and speed up audits from 2018 to 2024 using new resources. For all you unh panicans this is what's driving the pa

jnas_19

Article from Guardian this morning says Part 2 of UNH investigation coming tomorrow. Also... CMS LAUNCHES EXPANDED MEDICARE ADVANTAGE AUDIT STRATEGY; TO REVIEW ALL ELIGIBLE CONTRACTS, RECOVER PAST OVERPAYMENTS, AND EXPEDITE 2018–2024 AUDITS WITH NEW RESOURCES

WT-Financial

This story is dumb. CMS literally encourages participation in its Medicare Shared Savings Program (MSSP) as a way to reduce the cost of healthcare and improve patient outcomes. I hate United with a white hot passion, but it sounds like this writer has a poor understanding of US healthcare programs.

MikeHoncho1323

I got my stats from the commonwealth fund (well known healthcare spend/service tracker, and CMS.gov which is the official Medicare/caid website

chrislink73

We do not know for sure why he stepped down, it's just as likely that he didn't want copycat assassination attempts on himself or his family. I asked chatGPT what has happened to companies that have been found guilty of manipulating scores or other fraud related to Medicare Advantage. Here's what it had to say on the matter, "As of now, **no company has faced criminal penalties or total exclusion** from federal programs *specifically* for manipulating **Medicare Advantage risk scores**, but **some have faced major civil penalties**. The **most severe punishment** to date has likely been **civil settlements under the False Claims Act**, and the company that holds the distinction for the **largest known penalty** in this space is: # Sutter Health – $90 Million Settlement (2021) # Crime: * Submitting **inaccurate and unsupported diagnosis codes** for Medicare Advantage patients through affiliated medical groups to receive inflated risk-adjusted payments. # Details: * The U.S. Department of Justice (DOJ) alleged that Sutter knowingly **submitted false claims** to CMS. * A whistleblower initiated the case, and DOJ intervened under the False Claims Act. * The settlement resolved claims without an admission of liability. # Outcome: * **$90 million** paid to settle civil fraud allegations. * Sutter agreed to **enter a Corporate Integrity Agreement (CIA)** with the Office of Inspector General. * Subject to **ongoing compliance monitoring** and auditing. * Significant **reputational damage**." So for UNH to be fully excluded from Medicare Advantage, it would appear that would be the worst punishment for this crime that has ever been recorded, by far. But seeing as you are a professional in this space, I would defer to your judgement on the matter.

lucy_throwaway

I'm warning you just so in a few months I can look cool. They *have* to sacrifice profits to turn the tide on losing business due to massive unpopularity for claim denial practices. Profit will go down for the next few quarters because they will approve more claims or if they don't start approving more claims they will hemorrhage customers also reducing profit. If they aren't generous enough both of those things happen. The 15% cut to medicare/medicaid would justify a 25% drop until at LEAST the midterms assuming the dems win a majority and the risk of a big cut won't disappear until they take congress or the oval office. AKA the length of these contracts that risk is priced in. The alleged criminal investigation in a worst case scenario would work out to losing 35% of their revenue overnight if kicked off CMS for 5 years--I don't think it will happen but that risk will be priced in until it's resolved-- just like the above mentioned ones. There's a real case that 300 is undervalued but even if every single risk comes to pass by the time UNH hits 500 you'll have shed a huge portion of your time value for calls that *might* end up $10-20 ITM and run a huge risk of expiring worthless. You have enough money to buy NTM or ITM calls, why not take the easy money?

lucy_throwaway

Not really. The only real risk that could justify a share price much under 250 longterm is getting kicked off medicare/medicaid for 5 years for criminal medicare fraud AND a major cut to federal spending on medicare/medicaid AND continuing to lose lots of business due to the whole CEO assassination fallout. Given the absolute cluster fuck 9.4 million seniors needing new medicare advantage plans would cause, making an example of them would cause a lot of actual suffering and require some kind of crisis planning team at CMS in place just to weigh the feasibility of that punishment. Selling that (now banned) chunk of the business to a competitor is the only realistic option and even that would be a feat from an organizational standpoint. Keep in mind, there is probably no service on earth that requires more telephone based customer support than medicare advantage plans-- its the most tech illiterate audience period and the actual plans are insanely complex to understand, human support is inevitable. Basically, the government / the companies absorbing those plans would have to tip their hand well ahead of actually hitting them with that penalty just to avoid a catastrophe in continuity of care. Considering the fact that their ATH valuation was reality based and not dependent on future innovation miracles or an imagined short squeeze-- it's not a classic meme stock.

lucy_throwaway

CMS would need to convene a special crisis team to plan for the absolute cluster fuck of unprecedented scale that removing UNH from medicare would cause. 9.4 million people are on a UNH medicare advantage plan. The customer service hiring needed to absorb that many customers in other insurers would fill the worlds largest cruise ship, to say nothing of the other employees. Until we see every other player in the space going on an massive hiring spree and major reshuffling of execs internally to have absolute warriors at the helm of medicare departments this isn't real enough to warrant action from the competition. Or maybeeeee there could be a behind the scenes M&A play. Even then, the legwork required to pull something like that off would be way way too big to avoid leaks or rumors.

tomis_24

I worked in this industry! If there is Medicaid/Medicare fraud, it has to start with the patient, who would first have to defraud the government. Then the patient would have to defraud the doctor, and finally UNH. Before UNH is paid, Medicaid/Medicare validate the data and then issue payment. There are SOPs to identify and prevent frauds. DOGE reviewed CMS data and found no evidence of fraud by health insurers. UNH insiders have been buying stocks during the pullback.

GhostOfLaszloJamf

The admin is after Medicaid though, not Medicare Advantage, where UNH has been having its issues with MCR costs, which led to them suspending guidance due to higher utilization. When they did that they actually forecast a return to growth in 2026, largely because this Admin just significantly increased the CMS payment rate to MA plans for 2026. They increased payment rates for MA plans by 5.1%, the largest increase in the past decade, and more than double the 2.2% the Biden admin had proposed in January. The major healthcare incumbents like UNH and Humana were outright celebrating as they had seen their margins under extreme pressure during the Biden admin. I find it hard to believe people think this admin would be bearish for Medicare Advantage plays. Oz has advocated many times in the past for privatizing healthcare entirely, and making it all MA. The GOP has consistently favoured privatization and MA, and Trump and his cronies are much the same. These people all favour private sector. UNH and other big healthcare players have lots of issues, and this administration won’t magically erase all of them, but they shall very likely make the environment far more favourable for them through deregulation and payment rates. And to do so, they will gut Medicaid and the ACA like we are already seeing unfortunately.

Commercial-Speech122

Turnaround is practically a given. CMS pretty much ensures any MA contract's profit margin 5-10% and that's baked right into the rules of MA. If a carrier experiences higher costs, they can just bid for higher reimbursement next year. I like your putting things in perspective with the revenue vs market cap. However, remember that health insurance itself has super high turnover of cash because of all the claims during the year. Also, UNH expanded MA enrollment this past AEP by 4% while reducing workforce. All new members take 2-3 years to become profitable because of marketing costs and lack of medical history. Risk adjusted payments are reflected in the year following their new enrollment

Jdevers77

It’s a criminal investigation of their Medicare “Advantage” unit, in addition to the fine it’s unlikely but they could be dropped from CMS as a valid vendor. That has happened in the past but always with much smaller vendors. There are currently 9.9 million people who have that plan or just under 30% of the entire Medicare Advantage market. There are also nearly 8 million people that have other various Medicare products UHC sells which would also not be allowed if dropped-there is some overlap between those resulting in a total of just under 14 million people served by UHC using Medicare dollars. That would be devastating to the company.

badman_dont_PM_me

Medicare indirectly paid my salary for a while. If you’re positioned to get reimbursed by CMS directly, there is always some level of fraud. In a run of the mill case all that means is you were aggressive enough to get reimbursed for things that weren’t fully justified and then caught when audited. In egregious cases you pick up homeless people, enroll them in Medicaid and preform unnecessary procedures to bill the government. In the worst cases they just bill the government and never even attempt to provide something, sometimes never speaking with a patient. Usually the fines are less than the amount defrauded. It’s not as big of a deal as it sounds— assuming this was hugs and rainbows Medicare fraud.

90210j

UNH took a hit over CMS reimbursement rate concerns, but that seems largely priced in now. $460 held firm as support, and volume suggests some accumulation. With long-term fundamentals intact and a strong moat in managed care, downside from here looks limited unless we get another surprise from regulators or a miss in earnings. For long-term investors, this may have been the dip worth buying. That said, the market can stay irrational longer than your portfolio can stay solvent — so manage risk.

blackSwanCan

Sorry, but that seems like a failure on the part of CMS. Isn't it? Doesn't seem like there are clear definitions of risk either. So what is UNH accused off? Also, where does the CEO's departure come into the mix? Something seems off.

Virtual_Seaweed7130

All depends on your definition of fraud. The whole goal of CMS to try to turn a diagnosis into a number is trying to take something subjective and make it objective. That means some things are up for interpretation. Whether that crosses the line of fraud is up to the regulator. All this to say, the guardrails in place for outright fraud are numerous. As I say in the post, you’re talking about a slight hit to margins, not catastrophe.

movdqa

I have a hard time believing that the US would let UNH go bankrupt because they provide health insurance for so many people and so many companies. Other companies are pulling back in some of their markets making for even more provider shortages. I think that there was a boost to MA plans late last year which may help a bit and maybe CMS needs to do something to make MA as more of a viable business. Congress and HHS seems to want more people to go into MA and having MA companies fail is not a way to get there.

tomis_24

DOGE has been actively investigating Medicare fraud and found nothing substantial. They have access to CMS, and the only potential fraud is less than $30M, unrelated to UNH. PBMs have been on DOGE's radar, and the fact that they couldn't find anything speaks louder than the WSJ article. I am own UNH stocks.

Street-Debt-3847

How could I forget I had given CMS and extra key

IwearWinosfromZodys

Eew, why do you like it? UNH has gouged the government for years by over diagnosing patients and over billing the government. Although UNH won the billion dollar lawsuit against them because the government did not have enough proof, it shows CMS is starting to scrutinize their billing practices and living off the fat hog called the government for increasing payments yoy for the same level of care offered by UNH so it can continue to increase profits is over.

joepez

Yes and no. Yes in 30 days CMS is going to communicate a favored nation pricing (whatever that is). Then if in an unspecified time if substance (whatever that is) progress isn’t made then CMS will “ … shall propose a rulemaking plan to impose most-favored-nation pricing…”  This will direct CMS to propose a rule to do something to lower prices. How long will it take to propose? Who knows. If you know anything about CMS rules they take years to propose, debate and implement (usually with a grace period).  Again if real progress was to be made the President would be going to Congress to remove the constraints on negotiating prices. Multiple administrations (including the current one’s last rodeo) all tried and yet none have delivered. 

Upstairs_Implement87

Not exactly. 100M plus of their revenue is Medicare Advantage. Dr. Oz has to approve a rate increase because the customer is CMS. There are also insurance regulators in every state the can deny premium increases for their employer group segment. This isnt property casualty insurance, its health insurance. The government has a say in just about everything going on with their business. I still think its a good buy at 13x earnings, but dont think they can just premium hike their way out of it like an Allstate can. Source: I'm a healthcare actuary

dmelt01

In the US it was working like that with CMS which is what oversees Medicare. They negotiate a price they are willing to pay and often private insurance companies would agree to the same. Now more power has been taken away from CMS and insurance companies no longer care about getting lower costs. They just create insane deductibles so that the majority never reach an out of pocket maximum so they turn a profit no matter the price of healthcare.