Navigating Payer Challenges and Out-of-Network Policies with Jakob Emerson

Summary

Podcast Summary: Navigating Payer Challenges and Out-of-Network Policies with Jakob Emerson

Podcast: Becker’s Healthcare Podcast
Host: Scott Becker (Becker's Healthcare)
Guest: Jakob Emerson (Payer Industry Reporter)
Release Date: January 8, 2026

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Episode Overview

This episode features Jakob Emerson, a leading reporter on the U.S. payer industry, as he unpacks two major current topics:

• The highly publicized debate between Mark Cuban and Optum’s CEO regarding pharmacy benefit managers (PBMs) and the opaqueness of pharmacy costs.
• Anthem Elevance’s new policy imposing a 10% penalty on hospitals for out-of-network provider usage—a move sparking widespread concern across provider and policymaker communities.

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Key Discussion Points & Insights

1. Mark Cuban vs. Optum CEO: PBMs and Pharmacy Cost Transparency

[00:57 – 07:59]

• Background of the Event

  • Cuban and Optum’s CEO, Dr. Dirk McMahon (referred to as Dr. Conway in the transcript), held a lively and, at times, contentious conversation in Washington, D.C., moderated by a Johns Hopkins health policy professor.
  • The discussion centered around PBMs—OptumRx being one of the largest—and their role in driving up costs, maintaining opaqueness in how drug pricing works, and eschewing transparency for employers, plans, and consumers.

• Major Topics Debated

  • The Call to Break Up Conglomerates
    • Quote [04:09] (Jakob Emerson, paraphrasing Cuban):

      “Mark Cuban straight up just said, break up the big insurance companies so that they can't own PBMs, they can't own providers, they can't own their own technology. And to make them all independent companies…”

  • Pushback and PBM Defense
    • Dr. Conway (Optum CEO) responded that eliminating PBMs would shift costs directly to health plans, employers, and government bodies, as PBMs negotiate drug prices.
    • Pointed to the high cost of specialty drugs (e.g., GLP-1s) in the U.S. compared to Europe.
    • Claimed Optum contracts with 90,000 providers but only owns 10,000–12,000 directly.
  • Opaqueness and Employer Data Rights
    • Mark Cuban criticized the lack of transparency, especially for self-funded employers who cannot access detailed claims data from PBMs or insurers, even when they sue for it.
    • Quote [06:09] (Jakob Emerson):

      “…employers… it is very difficult, if not impossible to actually look through their claims data… they’ve sued for it and a lot of them have not won.”

  • Industry Disruption and Cuban’s Influence
    • Emerson highlights Cuban’s rapid rise in the pharmaceutical space since launching Cost Plus Drugs in 2022, and how his direct debate with Optum’s CEO signals both public appetite for reform and the industry’s growing openness to disruption.
    • Quote [07:40] (Jakob Emerson):

      “The fact that he's risen so quick, going head to head with one of the largest PBMs, I think, is… it says a lot about where the industry in general in pharmaceuticals is going.”

2. Anthem Elevance’s Out-of-Network Penalty Policy

[07:59 – 10:44]

• Policy Description

  • Went into effect January 1, 2026, for Anthem Blue Cross Blue Shield commercial plans.
  • Anthem can apply a 10% penalty on claims from in-network hospitals if an out-of-network provider (e.g., anesthesiologist) treats the patient at that facility.
  • Includes potential network termination as a penalty for hospitals.

• Industry Response and Rationale

  • Anthem claims this addresses unintended gaming of the No Surprises Act—a law set up to protect patients from unexpected out-of-network medical bills by mandating arbitration between providers and insurers.
  • Anthem alleges that some private equity and billing firms encourage out-of-network billing to secure large arbitration awards.
  • Providers are reportedly winning about 80% of arbitration cases, causing concern for payers.
    • Quote [10:44] (Scott Becker):

      “It’s amazing that providers are winning 80% of those claims. Is that what you said?”

    • Quote [10:46] (Jakob Emerson):

      “…providers are winning 80% of cases that reach arbitration under… the [No Surprises Act]. Simply absolutely fascinating.”

  • Major pushback from the American Hospital Association, Federation of American Hospitals, 14 physician-lawmakers, and provider groups, who argue hospitals can’t readily determine at the point of care whether all providers involved in a patient’s treatment are in-network.

• Concerns Raised

  • Likely to cause billing confusion and administrative headaches for hospitals and patients.
  • Could jeopardize provider-insurer relationships and network stability.
  • Reflects broader tension resulting from the No Surprises Act implementation and its arbitrage outcomes.

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Notable Quotes & Memorable Moments

• Mark Cuban’s Directness:

  • [04:09] Jakob Emerson relaying Cuban’s prescription:

    “Break up the big insurance companies so that they can't own PBMs, they can't own providers, they can't own their own technology…”

• PBMs and Opaqueness:

  • [06:09] Jakob Emerson:

    “…self-funded employers… have sued for [claims data] and a lot of them have not won. But it is true that health insurers, pharmacy benefit managers… don't want to give up complete medical claims data…”

• Rapid Disruption by Mark Cuban:

  • [07:40] Jakob Emerson:

    “…he's already… sitting here on a stage with the CEO of one of the largest healthcare companies… That really spells just how quickly he's gained in influence within this industry…”

• No Surprises Act Fallout:

  • [10:44] Scott Becker:

    “It’s amazing that providers are winning 80% of those claims. Is that what you said?”

  • [10:46] Jakob Emerson:

    “…providers are winning 80% of cases that reach arbitration under… the No Surprises Act. Simply absolutely fascinating.”

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Important Timestamps & Segments

• [00:58] — Introduction of key issues and Optum CEO vs. Mark Cuban debate
• [01:57] — Details on the Washington panel discussion, main points of contention
• [04:01] — How Mark Cuban and Dr. Conway would rewrite healthcare policy
• [06:09] — Employer frustration with “opaqueness” and lack of access to data
• [07:40] — Mark Cuban’s rapid rise as a disruptor in pharmacy
• [08:10] — Anthem Elevance 10% penalty policy on out-of-network provider use
• [10:44] — Arbitration under the No Surprises Act: 80% win rate for providers

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Tone & Closing Observations

Jakob Emerson delivers his analysis with an even, highly-informed tone, often paraphrasing and channeling the bluntness characteristic of Mark Cuban. The conversation is briskly analytical, packed with topical data and clear-eyed observations about payer strategies and regulatory fallout. Scott Becker brings a sense of urgency and gratitude, emphasizing the value of insights shared in a compressed format.

Memorable Closing
[10:57] Scott Becker:

“I get more information in a shorter period of time on what’s really going on with payers and providers than with talking to you than anybody else.”

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Summary Takeaway

This episode distills two of the most pressing ongoing controversies in U.S. healthcare:

• The future of PBMs and the intense pressure for transparency, driven in part by high-profile disruptors like Mark Cuban.
• The ripple effects of the No Surprises Act on payers and providers, now manifesting in potentially punitive network policies that risk adding complexity to both provider operations and patient experience.

Listeners leave with a deep understanding of the payer-provider battlefield circa early 2026, armed with quotes, context, and the leading-edge insights from Jakob Emerson.

Transcript

[A]

This is where healthcare leadership comes together. Becker's 16th annual meeting brings more than 3,500 hospital and health system executives and nearly 800 speakers to Chicago, April 13th through the 16th. This year's event includes keynote conversations with Dallas Cowboys legend Troy Aikman and former President George W. Bush. For the agenda and event details, visit Beckershospitalreview.com and click on the Events tab in the upper right. We're looking forward to hosting you in Chicago.

[B]

This is Scott Becker with the Becker's Healthcare Podcast. I'm thrilled to be joined by Jacob Emerson. Jacob covers the payer industry better than anybody in the country. He gives us regular updates on what he's watching with the country's payers and the dynamic between payers and health systems and consumers. Quite frankly, Jacob, let me tee it up and ask you to take it away. What are a couple of the key issues that you're watching currently?

[C]

Currently? Hey Scott, it's good to talk with you. I thought two big stories we could talk about. One happened last month in December where we saw Optum's CEO and Mark Cuban have a very lively conversation in Washington over pharmacy costs, PBMs, all that good stuff that they both focus on. And then another story that our readers have been really interested in recently is a new policy from Anthem elevance and a 10% hospital penalty that they are going to to put on claims from hospitals when they use out of network providers. So for example, if a physician group is out of network with Anthem, but the hospital is not applying a 10% penalty on that hospital for using that out of network provider, and I can explain more details there in terms of what that entails.

[B]

Thank you. First, let's talk about the Conroy Cuban discussion debate. I saw some of it around Twitter and X, but didn't really understand what was going on. Yeah, I saw your article on it. Tell us what, what happened? What was that?

[C]

Yeah, and I, you know, we were one of the only outlets that covered this because it was, it was actually difficult to get our hands on the footage. But basically the two, the two individuals, they sat down, it was mid December last year in Washington at an event hosted by Johns Hopkins and it was moderated by one of their health policy professors. And basically, you know, they talked about, I mean, a lot of things. It was an hour long conversation, but it was, it was centered really, I would say on pharmacy benefit managers, which of course Optum or OptumRx is one of the largest in the country. And they talked about the rebate system Just the high cost overall of pharmaceuticals, especially specialty drugs in this country. And then you know, some of the, the opaqueness of that industry, which, you know, everybody is familiar with, I think everybody is very confused for the most part by this industry because of how complicated it is, how opaque it is in terms of these contracts and how these all work together. And so that also then you know, kind of led to them talking about price transparency or a lack thereof for both employers and health plans and then also then for consumers on the ground and ultimately what they pay at the pharmacy counter and why that is often so confusing in the US So it was a lot of different things, but as you can imagine, it got pretty contentious at points. At points there were expletives thrown out. At some points with Mark Cuban straight up just saying bullshit to stuff that Dr. Kanye, Dr. Conway was so, you know, watching it overall was, was pretty interesting and I can detail, if you'd like, a little bit more about what specifically they talked about, slash debated.

[B]

Jacob, do us a favor, tell us what are a couple of the issues that they, that they talked about. It seems like in the US we've got this massive cost structure going on in health care between the payers, the health systems, everybody else, the pharmaceutical companies just seems like it's become so inflated and so challenging and health systems are having a very hard time making all the numbers work anyways. But what did they, what are some of the details of what they discussed?

[C]

Yeah, let me, let me just go through some of the high level points that really stood out to me when I listened to this conversation, Scott. And of course they diverge on a number of issues. But I thought what was interesting was when the moderator asked them specifically just how they would rewrite national healthcare policy. And Mark Cuban straight up just said, break up the big insurance companies so that they can't own PBMs, they can't own providers, they can't own their own technology. And to make them all independent companies, which I think is easier said than done, but definitely points to the wider trend, of course, that we've seen over these last 5, 10, 15 years of these massive conglomerates buying up almost every part of the health care industry, including UnitedHealth Group, probably the best example of it, because they are the largest. And Dr. Conway did push back, talking about how, you know, Optum specifically, they don't own more than about 10 to 12,000 physicians directly or the medical groups that they, they work in, but they contract with almost 90,000 of them. So, you know, kind of a kind of a tricky way of, I think of explaining it. But at the end of the day, you know, United, like I mentioned, they are the largest health care company, largest insurer, pbm, they have the data firm with Change Healthcare, they own a ton of ASCs and medical clinics. But, but Dr. Conway said that he believes that at the end of the day it's a cost issue. It's ultimately what the pharmaceutical companies are charging. And, and that is fair given if you just look at GLP1s, we know that they're extremely expensive compared to what they cost in Europe. So he is correct there. He also said that, you know, just getting rid of like a pbm, for example, would or would basically transfer a lot of those pharmaceutical costs directly to health plans, to unions, to government bodies, employers in general. Because he argues that his PBM, OptumRx, is basically negotiating those, those prices for them so that things would be much more expensive if they didn't exist. And then, you know, Mark Cuban responded, well, why are we the only country in the world that has the concept of pharmacy benefit managers? So there's that. And then Mark Cuban talked about, you know, just the opaqueness of the industry, like I mentioned earlier, Scott, and how a lot of employers, you know, when they contract, self funded employers, when they contract with PBMs or with health plans, that it is very difficult, if not impossible to actually look through their, their, their claims data that a lot of, and they've sued for it and a lot of them have not won. But it, but it is true that health insurers, pharmacy benefit managers, whether you consider those the same thing, they don't want to give up complete medical claims data because well, there's probably a lot of reasons and I think Mark Cuban would be the better one to, to say exactly why, but that is a very real thing, is that employers right now don't really know the full extent of, I think, where their money is going under these, these contracts with these large companies. So debated that debated PBM rebates and how they affect what patients are paying at the pharmacy counter. But I think one last thing I wanted to say on this, Scott, is that broadly and like contextually, what, what is really fascinating about this is Mark Cuban only launched cost plus drugs in 2022, focusing originally on generics and pretty much still very focused on that with a few more biosimilars and specialties that they've rolled out since. And, and he's already four years later sitting here on a, not even four years later sitting here on a stage with the CEO of one of the largest healthcare companies in, in the country in the world and debating him directly on these issues. And so to me, that really spells just how quickly he's gained in influence within this, within this industry, but also that how, how, how much appetite there is for disruption within it. The fact that he's risen so quick, know, going head to head with one of the largest PBMs, I think, is, it says a lot about where the industry in general in pharmaceuticals is going.

[B]

Yeah, no, it's, it's literally remarkable. And talk a bit about what's going on with the elevance out of network issue in health systems. Talk a bit about that.

[C]

Yeah. So this has been getting a lot of attention from the hospital associations and from federal lawmakers alike. And it's just for the provider community in general, because of course, Anthem is, I believe, the second largest insurance company in the country with anywhere from 45 to 50 million members all over the country. And so this basically affects all providers. And basically this, this new policy, it went into effect on January 1st and it imposes a 10% penalty on claims coming from hospitals that involve out of network providers for their Anthem Blue Cross with Shield commercial plans, along with a potential even for network termination. And basically that means that if the hospital, for example, was using a physic group or an anesthesiologist or that was not in network with Anthem that treated the patient, but the patient went to the hospital because that hospital was in network, then Anthem can then apply that 10% penalty. And basically what Anthem here is arguing is it comes down to some of the unintended effects we're now seeing play out from the no surprises Acts and that arbitration process that was set up to basically allow out of network bills to be mediated between insurers and providers. And Anthem has basically been saying through this, and honestly, very publicly, their exec, their CEO has been saying it, they've been saying it through lawsuits that this system is being gamed and that there's a lot of, according to them, private equity groups, third party billing companies that are really encouraging out of network billing to secure massive arbitration awards. And it is true that providers at this point are winning about 80% of those arbitration that go or those issues that go to arbitration. So insurers definitely are, are losing here. But as you can imagine, hospitals are not, you know, very, not very pleased with this because they're basically saying we can't figure out when a patient comes to us whether, you know, their health plan covers us and the physician group or either or we can't do that at the time of the service. And so this is just going to create a lot of billing issues for patients. And then so like I said, hospital, American Hospital Association, Federation of American hospitals and then 14 physician lawmakers in Congress all coming out saying anthem, do not put this into place. It did go into place on the first but as as you can as you can tell, just very controversial and not something I think we've seen from insurers as of as of yet besides this and all really going back to the to the no surprises act.

[B]

Fascinating. And it's amazing that providers are winning 80% of those claims. Is that what you said?

[C]

That's according to some of the most recent research that yeah, providers are winning 80% of cases that reach arbitration under under the n. Simply absolutely fascinating.

[B]

Jacob, I want to thank you as always for joining us on the Becker's Healthcare podcast. I get more information in a shorter period of time on what's really going on with payers and providers than with talking to you than anybody else. I want to thank you for joining us. Thank you so much.

[C]

Thank you, Scott.