In Episode 3 of The Political Pulse, hosts John Thompson and Hannah Rice recap the opening days of North Carolina’s legislative session and the healthcare issues already driving 2026 priorities.

Short Session Starts and Stakes Are Set

John Thompson and Hannah Rice open the legislative session recap by framing 2025 as a major year for North Carolina healthcare policy and warning that 2026 is shaping up to be just as consequential.

Medicaid Takes Center Stage

They highlight bipartisan movement to address a $319 million Medicaid funding gap and describe broad agreement among legislators that Medicaid is too expensive even as access-to-care problems persist.

What’s Next

They preview upcoming budget fights, continued negotiation of the CARE First Act, and ongoing monitoring of scope of practice, while urging members to share stories and cost-saving ideas.

I have the good fortune of being married to my best friend. He truly is my soulmate and compliments everything in my life. Yes, I am one of those people who believe there’s one special person for everyone, and I was blessed enough to have met that person and even more blessed to get to spend my aging days with him.

My favorite thing about him is his laugh. He has the best laugh in the world and even on my worst days thinking about it makes me happy. His smile can light up a room, and the quickest way to erase that beautiful smile is to have him take out our dog. Champ is our 100lbs Bernadoodle, who absolutely did not get the poodle memo. He is all Bernese Mountain Dog which is apparently code for “I have a mind of my own.” Our biggest frustration is when he fails to listen, particularly when we take him outside, which vexes my husband beyond belief. My very even keeled husband becomes unrecognizable as our dog wanders around the backyard trying to find an optimal place to do his business. I can literally hear him yelling, “Just do it!”, as Champ is distracted by every little twig, chirp or breeze that blows by. It frustrates me too, and I’ve yelled that on more than one occasion, but I’m clearly focused on my husband, so bear with me.

Ironically enough, my husband is from Wilmington, having attended Laney High School not long after my beloved Tar Heel’s basketball phenom Michael Jordan. Just in case you’re not from North Carolina and have absolutely zero interest in anything sports (it could happen!) … Michael Jordan is one of the most iconic figures in the history of college and professional basketball. He has also dabbled in baseball, golf, NASCAR, Hollywood … the list goes on. And if you do know anything about Michael Jordan, you’re more than familiar with his worldly influence with the slogan, “Just Do It”.

Last week, I learned after nearly a decade of physicians pushing to “Just Do It” and provide better data, CMS issued a final rule back in January 2024 requiring certain Medicare Advantage (MA) and Medicaid Managed Care Organizations (MCO) to report prior authorization metrics annually starting in 2026. The covered entities must disclose annual, aggregated data specifically regarding their prior authorization for medical services (excluding drugs). The first set of those metrics were released on March 31, 2026, and what we’ve learned is quite interesting. Now, remember, this data is NOT for commercial insurance products, but it’s still staggering.

On average, health insurers denied 7.7% of prior authorizations. Of those denials, only 11.5% were appealed. Now, since I did not go to the math school, I attended the artsy-fartsy one, let’s break this down. For every 100 prior authorizations submitted, health insurers denied a little under 8. And for every 100 of those denied PAs, only 1 was appealed. ONLY ONE! Add the fact that when a physician appealed the PA, a whopping 80.7% of those denials were overturned. 80.7%! Again, my math skills are not like that of my engineer husband, but that’s 4 out of 5 times! You don’t have to be a 5-time winning NBA MVP to know … Just Do It!

We know why physicians don’t take the time to file appeals. The process is cumbersome. It’s time-consuming and infuriating. It delays care which potentially harms patients.

However, what this data tells us is prior authorizations are terribly misused and not clinically sound. Just Do It! If over 80% of the time, an appeal is upheld, you’re going to get approved! Just Do It! Four out of 5 times, you are now holding the payer accountable. Just Do It! Your North Carolina Medical Society is working hard to solve this and other unnecessary utilization management programs and finding ways to work with health insurers to create the appropriate mechanisms to correctly control costs, manage financial risk and shift clinical decision making back to physicians. Until then, let’s all be like Mike … Just Do It!

I love being the mom of a teenager. It offers such insights into the things I don’t know or understand. Like language barriers, for instance. My darling daughter was sharing a story with me recently about someone she’s not very fond of. “Bruh, he’s just chud.” “I’m sorry, chud?” I responded. “Chud,” she said. “Facts, mom. He’s just ugly.” I wasn’t sure if she was referring to his appearance or his aura, so she thoughtfully clarified it could be applied to both. Being a child of the 70s and 80s, I’m fully aware of speaking with such confusing and altered language. “Grody.” “Chill.” “Gag me with a spoon.” “WHATever!” She doesn’t have much on me with that. However, her sarcasm and wit are entirely more sophisticated. All of that to say, it just reinforces as time passes; some things never change. Facts, mom. Facts. Riiight – Right – Right. Bruh!

Ironically, that thought process leads me to health insurers and how interactions with physician practices have evolved over the years – or haven’t. Confusing and altered language seems to be the norm when interacting with payers. We’ve become accustomed to terminology without truly understanding the meaning: clinical vs. administrative; coding vs. narrative. These language barriers contribute to delays, denied claims, physician burnout, and potentially compromised patient care.

For entirely too many years, we’ve allowed these barriers to weave themselves into the complexity of healthcare, to the point we struggle with meaningful conversations. Thus, they play a significant role in shaping many of the legal disputes in today’s healthcare.

For example, a RICO (racketeering) lawsuit has been filed against Express Scripts and its parent company, Cigna, accusing the PBM of using a Swiss entity, Ascent, to siphon money from drug manufacturers instead of passing rebates on to clients. Another example, Aetna agreed to pay $117.7 million to resolve False Claims Act allegations it submitted or failed to correct inaccurate diagnosis codes for Medicare Advantage patients, allegedly inflating payments received from the federal government.

And yet another example, UnitedHealthcare is also facing a lawsuit and investigations over inflated Medicare Advantage payments by manipulating patient diagnoses to make them appear sicker, triggering higher reimbursements.

These cases are not just about dollars or compliance – they reflect deeper, systemic misalignment in how care is communicated, interpreted, and justified. Until we address the fundamental language divide between physicians and insurers, we will continue to see these conflicts escalate beyond administrative friction into legal battles that ultimately affect the entire healthcare system.

Did I mention I’ve been in this industry for 30 years, now back at NCMS doing the exact same thing I did 25 years ago? Facts. Riiight – Right – Right. Bruh!

Hi everyone … Happy Thursday! It’s MARCH MADNESS! And man … no catch-phrase could be more appropriate! March is one of my favorite months because it celebrates my birthday, my daughter’s birthday and my Tar Heels as they move through post-season basketball. Our girls rolled into the Sweet Sixteen! Girl Power, ladies! Good luck against UConn! It’s going to be a tough game, but Tar Heel Nation is rooting for you! As for our boys – there are no words. The news of Coach Davis just breaks me. Hubert was at Carolina my first two years of college, and I’ve always been a fan. Thanks for everything, Coach! My heart still soars for your first-year wins against that darker shade of blue eight miles away! (Tears rolling down my cheek)

Now … for the REAL reason you’re here. Sadly, there are so many ways physician practices are negatively impacted by payment structures right now in healthcare. I wasn’t sure where or how to start. So, I decided to just go with what I know best … Downcoding. Downcoding of CPT codes is when payers reduce the level of service billed by a provider to a lower-paying code. Typically, this is done automatically without any clear rules or guidelines from payers, making it difficult for practices to adapt their workflows. Nationally, this type of program has been going on for years – California started seeing it in 2019 – we just happened to be one of the last states standing with implementation.

As you may recall, NCMS began working on this issue last summer as Aetna began their downcoding program March 1st – WOW, didn’t make that connection until just now! We’re well aware of the impact, both operationally and financially, these programs impose. We are working specifically with Aetna to better understand their program and were told many practices have achieved exemption status for three years – Congratulations! If you have not been granted this exemption, please let me know. We’ll do what we can to facilitate.

The larger issue at stake and what we need focus on is Utilization Management as a whole and how these programs are used to manage payments to practices. It’s not just downcoding, but prior authorization, medical necessity review, bundling/unbundling edits, the list goes on and you’re well aware of each component. We need to realize these programs shape both what care is delivered and defines how much physicians are paid. And, in my personal opinion (which I get to share since I manage this blog), it’s okay for physicians to get paid. You’ve spent the better part of your lives educating yourselves, training, and working solely to take care of your patients. There’s nothing more pure than that.

Healthcare is constantly evolving. The policies, the payers, the pressures — they shift, stack up, and compound in ways that affect not just how medicine is practiced, but whether independent practices can survive and thrive. For too long, the business side of medicine has been treated as secondary. Something to figure out along the way. A necessary inconvenience tucked behind the real work of patient care.

That ends here.

Welcome to The Tar Heel Payer & Practice Blog, published by the North Carolina Medical Society. I am your author, Jenni Hines, and I am glad you are here.

A Little About Me

I bring 30 years of experience in the healthcare industry to this space. This is three decades of watching the landscape shift, navigating the complexities of payer relationships, and working alongside physicians who are doing everything right clinically while fighting an uphill battle on the business side. That experience shapes everything I write here.

This blog is not about theory. It is about what is actually happening in physician practices across North Carolina. The real challenges, the real stakes, and the real conversations we need to be having.

Why This Blog. Why Now.

Here is a truth that does not get said enough: nearly every other sector in healthcare operates with a clear focus on financial sustainability and often profitability. Hospitals. Health systems. Insurance companies. Pharmaceutical manufacturers. They all run with business discipline at the center of their model.

Physician practices? Too often, they are expected to operate differently. To absorb cuts, navigate complex payer rules, manage prior authorizations, and keep the lights on all while the financial realities of running a practice grow more demanding by the year.

It is time to challenge that long-standing mindset. Strengthening the business of medicine is not a compromise of values. It is essential to protecting independent practices and ensuring physicians can continue delivering high-quality care to the patients who depend on them.

What You Can Expect Here

Through this blog, I will dig into the issues that matter most to physician practices in North Carolina. That means breaking down payer policies and what they mean in practical terms. It means exploring practice management topics that do not always make it into continuing education or board meetings. And it means fostering a deeper, more honest understanding of the financial and operational realities that come with running a practice today.

Sustaining a successful physician practice requires not only clinical excellence but also a strong grasp of what is happening on the business side of the exam room door. This blog exists to help with that.

Some posts will be analytical. Some will be practical. Some will challenge assumptions that have gone unquestioned for too long. All of them will be grounded in experience, informed by research, and written with one goal in mind: giving North Carolina physicians and practice leaders the insight they need to navigate what is ahead.

Let us Get Into It

The issues facing physician practices in North Carolina are not going away. Payer policies are growing more complex. Reimbursement pressures are real. The administrative burden on practices continues to climb. But so does the community of physicians, practice managers, and advocates who are committed to pushing back, finding solutions, and making the business of medicine work.

That is the conversation this blog is built for. I am glad to be having it with you.

Stay tuned. There is a lot to talk about.

That’s what Episode 2 of The Political Pulse is all about.

Host John Thompson is back with co-hosts Ashley Rodriguez, Jenni Hines, and Hannah Rice for an episode that blends Elections 101 with a deep dive into North Carolina’s primary results. Because if you want to understand what just happened at the ballot box, you first have to understand how the system works.

Start With the Fundamentals

Before the analysis, the team lays the groundwork. How do primaries actually function in North Carolina? How do candidates secure their party’s nomination? And how does voter turnout shape outcomes in ways that ripple far beyond Election Day? If you’ve ever felt like political coverage assumes you already know the rules, this episode is for you.

Then the Real World Results

Once the foundation is set, the hosts get into what voters actually decided. Who won? Who surprised? Where did voter energy show up and where did it fall flat? The team breaks down the results with an eye toward what they signal for the general election and the upcoming short session in Raleigh.

For health care providers and advocates, these results matter. The candidates moving forward will be the ones making decisions about payer policy, Medicaid, scope of practice, and a host of other issues that shape the environment you work in every day. Understanding who they are and how they got there is the first step to staying ahead of what comes next.

Why It Matters for Healthcare

Elections are the mechanism through which policy gets made. The primaries just told us a great deal about where North Carolina’s political energy is heading. The Political Pulse exists to connect those dots between the ballot box and the exam room, between the campaign trail and the committee room.

This episode does exactly that.

Health care doesn’t happen in a vacuum. Every decision made in a legislative chamber, every shift in payer policy, every budget negotiation in Raleigh has a ripple effect. These actions eventually reaches your exam room, your staff, and your patients.

That’s exactly why we built The Political Pulse.

This is the North Carolina Medical Society’s newest resource for cutting through the noise and getting to what matters with clear, informed analysis of the policy conversations shaping health care in our state. Whether you’re a physician trying to understand how the latest legislative session affects your practice, or a health care advocate tracking the evolution of payer policy, this podcast was made with you in mind.

Meet the Team

At the helm is John Thompson, who brings the experience, perspective, and sharp instincts needed to navigate North Carolina’s complex policy landscape. John is joined by co-hosts Ashley Rodriguez, Hannah Rice, and Jenni Hines who collectively bring depth, diverse viewpoints, and a genuine commitment to keeping North Carolina’s health care community informed.

Together, they’re not just reporting on policy. They’re helping you understand it.

Why Now

North Carolina’s health care landscape is in the middle of a significant moment. Legislative priorities are shifting. The decisions being made today will shape the environment providers work in and the care patients receive for years to come. The Political Pulse launches at exactly the right time, and we don’t intend to miss a beat.

We’re glad you’re here for it.