UX/CX Designer

Exclusive-TPG explores $5 billion sale of healthcare software company Lyric, sources say. 10 Sep 2026 03:52AM (Updated: 10 Sep 2026 04:06AM) Add CNA as a trusted source to help Google better understand and surface our content in search results. NEW YORK, Sept 9: Private equity firm TPG is exploring the sale of Lyric, in a process that could value the software company which supports payments in the healthcare industry at about $5 billion, people close to the discussions said. The move comes as software dealmaking has shown signs of recovery after concerns about artificial intelligence disruption triggered a selloff across the software sector earlier this year. As activity picks up, there remains wariness about what businesses are worth, and to what extent even highly specialized software providers could be affected by the technology's rapid evolution. Insurers such as UnitedHealth, CVS and Humana hire Lyric to identify and prevent inaccurate medical claims payments. TPG is working with investment bankers at JPMorgan Chase on a possible sale of Lyric, said the sources, who cautioned that there is no guarantee that the sale process will lead to a deal for Lyric, and also spoke on condition of anonymity to discuss private deliberations. The company generates about $250 million of annual earnings before interest, taxes, depreciation and amortization, or EBITDA, which normally could put it at a valuation of $5 billion considering a 20 times multiple, the people said. TPG and JPMorgan declined comment. Lyric didn't immediately respond to a comment request. AI DISRUPTION TPG acquired ClaimsXten for about $2.2 billion in 2022. The business had been part of Change Healthcare, but was sold to help smooth potential antitrust hurdles which threatened to derail Change's $13 billion acquisition by UnitedHealth. TPG rebranded the company as Lyric the following year. The investment firm has previously said that, since then, the company has experienced a significant acceleration in revenue growth. While the size of the growth is undisclosed, TPG said Lyric had benefited from the deployment of AI, and its dataset-rich business would compound those benefits. Despite this, some prospective software-company buyers are assessing whether AI-native competitors could ultimately perform many of the same functions more cheaply. This could undermine the financial assumptions used to value companies, including payment-integrity and claims-management technology firms, the sources said. Reflecting uncertainties in the space, the stock of smaller public peer Claritev tumbled 80 per cent between September 2025 and May this year as investors fretted about AI disruption to software companies. While it has recovered since then, it is still trading below $38 per share, from $72 per share one year ago.

UnitedHealth is trouncing the market in 2026. Is the stock still a buy? This recovery story is turning into a success story. By Adria Cimino - Sep 4, 2026 at 3:50AM EST Key points. * Headwinds weighed on UnitedHealth's earnings last year, but the company today is better managing challenges. * UnitedHealth recently lifted its full-year earnings forecast. * 10 stocks The Motley Fool, LLC like better than UnitedHealth Group" Last year, UnitedHealth Group's (UNH +0.32%) struggles with rising medical costs weighed significantly on earnings - and on stock performance. But the company has since put into place a plan to turn things around, and that plan has been bearing fruit. Though UnitedHealth's challenges haven't disappeared, the company is better navigating the current market, and efforts are paving the way for long-term growth. Earnings in the recent quarter, which surpassed estimates, confirmed this positive momentum. And investors haven't ignored this important turnaround story. They've piled into UnitedHealth shares, sending the stock to a 21% gain so far this year. Considering this market-beating performance, is the stock still a buy? Let's find out. The rising cost of medical care. So, first a quick look at the headwinds facing UnitedHealth - and its fellow health insurers. The rising cost of medical care is an issue that probably won't go away, and it hurt UnitedHealth last year, particularly since the company underestimated patients' use of medical services. But wisely, UnitedHealth decided to adapt its operations to better manage these higher costs moving forward. Efforts included dropping certain plans that were too costly, increasing premiums, and investing in artificial intelligence (AI) to gain efficiency. The idea is that, since it's unlikely medical care costs will drop, UnitedHealth today and into the future will be better prepared to operate in a high-cost environment. In the quarter, the company's efforts across benefit design and network curation drove better- than-expected results for its Medicare Advantage business. That said, UnitedHealth continues to face high costs across its commercial offerings, a trend that's impacting the entire industry. The company says recovery in commercial margins will be a focus "longer than originally anticipated." This will be a key point for investors to watch. UnitedHealth Group Premium Feature Moneyball Superscore ( 0.32 %) $ 1.28 Current Price Key data points. Market Cap Day's Range $ 395.30 - $ 405.16 52wk Range $ 255.97 - $ 461.62 Dividend Yield UnitedHealth increases its outlook. But, overall, UnitedHealth's moves so far have been successful, and that may be seen in the latest earnings figures. The company reported adjusted earnings per share of $6.38, up from $4.08 in the same period last year and surpassing analysts' expectations. Meanwhile, the company increased its full-year adjusted earnings per share outlook to the range of $19.50 to $20. That's up from the prior estimate of $18.25 or greater. Where to invest $1,000 right now. When its analyst team has a stock tip, it can pay to listen. After all, Stock Advisor's total average return is 983%* - a market-crushing outperformance compared to 212% for the S&P 500. They just revealed what they believe are the 10 best stocks for investors to buy right now, available when you join Stock Advisor. *Stock Advisor returns as of September 4, 2026. Importantly, the company's medical care ratio came down to 86.7% from 89.4% in the same period a year ago. This ratio measures the percentage of premiums spent on medical care. A lower number is better for the insurer financially, though regulatory limits mean this percentage shouldn't drop too low. Insurers generally aim for 80% to 85%. It's key to note that UnitedHealth operates two units, the UnitedHealthcare insurance business and the Optum health services business. This, along with the fact that UnitedHealth is the biggest U.S. health insurer, offers the company a solid moat or competitive advantage. It would be difficult for a rival to upset UnitedHealth's market position. Now, let's consider the stock's performance and whether this player still should be on your buy list. As mentioned, UnitedHealth stock has climbed in the double digits this year as investors tracked the company's progress over the past couple of quarters. This has driven an increase in valuation, with the stock trading at 20x forward earnings estimates, up from a low of around 15x earlier this year. But, this level is still much lower than the peak of more than 35x reached last year. UnitedHealth may not be dirt cheap, but it has demonstrated over the past year that its plan to address the challenge of higher healthcare costs is working. So, considering the company's efforts and progress so far and the full valuation picture, it remains reasonably priced. All of that means that UnitedHealth, even after recent gains, is a stock to buy and hold onto as this recovery story could deliver more good news over time. Should you buy stock in UnitedHealth Group right now? Before you buy stock in UnitedHealth Group, consider this: The Motley Fool Stock Advisor analyst team just identified what they believe are the 10 best stocks for investors to buy now... and UnitedHealth Group wasn't one of them. The 10 stocks that made the cut could produce monster returns in the coming years. Consider when Netflix made this list on December 17, 2004... if you invested $5,000 at the time of its recommendation, you'd have $2,230,785!* Or when Nvidia made this list on April 15, 2005... if you invested $5,000 at the time of its recommendation, you'd have $6,886,785!* Now, it's worth noting Stock Advisor's total average return is 983% - a market-crushing outperformance compared to 212% for the S&P 500. Don't miss the latest top 10 list, available with Stock Advisor, and join an investing community built by individual investors for individual investors. *Stock Advisor returns as of September 4, 2026.

CVS Caremark, Express Scripts, OptumRx: how PBM drug appeals differ - september 2026. CVS Caremark, Express Scripts, OptumRx: How PBM drug appeals differ. If you've ever sent what felt like a solid prior authorization appeal to a PBM and gotten crickets, or worse, an automatic denial, you already know that not all pharmacy benefit managers play by the same rules. CVS Caremark, Express Scripts, and OptumRx collectively manage pharmacy benefits for the majority of commercially insured Americans, and each has built its own appeal process with its own quirks, timelines, and pressure points. What works for an Express Scripts formulary exception request may fall completely flat with Caremark. Understanding these differences is what separates a patient who gets their medication from one who doesn't. Why PBMs don't all think alike. PBMs aren't passive claims processors. They operate under contracts with health plan sponsors - employers, unions, government programs - and those contracts determine which drugs get covered, what step therapy looks like, and how much latitude a reviewer actually has when reading your appeal. OptumRx is deeply integrated with UnitedHealth Group's clinical infrastructure, so formulary decisions tend to align tightly with UnitedHealthcare's medical policy. Express Scripts, now operating under Evernorth as Cigna's health services arm, has historically taken a formulary-first approach with significant rebate-driven exclusion lists. CVS Caremark occupies a different position because of its vertical integration: it owns retail pharmacies, specialty pharmacies, and a health insurer in Aetna. That creates real conflicts of interest, but also specific leverage points for a well-placed appeal. Knowing who you're dealing with shapes how you argue a case. CVS Caremark: documentation depth is your friend. Caremark's appeal process rewards thoroughness. Clinical reviewers are accustomed to detailed medical rationale, and a two-paragraph appeal rarely moves the needle for a specialty drug. A few things worth knowing: * Step therapy disputes are common. Caremark frequently requires trials of preferred formulary alternatives before approving a branded agent, even when the prescriber has strong clinical reasoning for bypassing that sequence. * The formulary exception pathway is separate from the prior authorization appeal. Many billing teams treat these as the same thing. A formulary exception argues that the plan's preferred drug is medically inappropriate for this patient; a PA appeal challenges a denied authorization. Knowing which one applies matters. * Clinical notes, not just opinions, drive decisions. Reviewers want documented evidence of previous treatment failures, contraindications, or specific clinical indicators. Pull the actual chart notes, lab values, and relevant history. One practical note: Caremark's online portal forms often have character limits that will truncate a detailed clinical narrative. Always attach a separate clinical summary document rather than relying on the portal text fields alone. Express Scripts: know the formulary exclusion list cold. Express Scripts maintains one of the most aggressive drug exclusion lists in the industry. Each year, more branded drugs are removed from coverage in favor of biosimilars or competing generics, and January 1 formulary changes catch plenty of practices off guard. For appeals, the first thing to determine is what actually drove the denial: * A formulary exclusion (often non-appealable without a true formulary exception pathway) * A clinical criteria denial (absolutely appealable with proper documentation) * A quantity limit or duration-of-therapy issue (frequently winnable with the right supporting data) Express Scripts tends to be more rigid on formulary exclusions than the other two. If a drug is excluded, you're generally working through a formulary exception process that requires documented evidence the patient tried and failed on, or has a contraindication to, the preferred alternative. "The patient prefers this medication" goes nowhere. "Patient developed [specific adverse event] on [preferred alternative] documented on [date]" is the kind of language that actually works. Their peer-to-peer review process is worth pursuing when you can get it. A prescriber willing to spend 20 minutes on a call with an Express Scripts clinical pharmacist will see approvals at a higher rate than written appeals alone. Flag this option for your providers. OptumRx: use the UnitedHealth clinical framework. OptumRx appeals have a specific strategic angle available that the other two don't offer as cleanly: alignment with UnitedHealthcare's published clinical policies. Because of the integration between OptumRx and UHC, criteria documents are often publicly available and detailed. If you're appealing a clinical criteria denial, finding the exact policy cited in the denial and then building your appeal around the specific language in that policy is genuinely effective. A few things that work well: * Reference specific clinical guidelines (ACC, ADA, ASCO, and similar) that support the prescribed therapy. Reviewers respond to evidence-based frameworks. * Confirm specialty pharmacy routing before escalating. OptumRx has a preferred specialty pharmacy network, and sometimes a denial is partly logistical. Sorting out routing early can save a full appeal cycle. * Expedited appeal timelines are real. For oncology, transplant medications, and acute psychiatric conditions, OptumRx does process expedited appeals within 24 to 72 hours. Request expedited review explicitly and document the clinical urgency clearly. One field observation: OptumRx's online provider portal has improved, but fax-based appeal submissions still work and sometimes process faster. It's worth knowing. Building an appeal that holds up across all three. The PBM-specific differences matter, but certain fundamentals strengthen appeals regardless of who's reviewing them. They're consistently missed even by experienced billing teams: * Match your clinical argument to the specific denial reason cited. A generic appeal that doesn't address the actual criteria is easy to deny again. * Put the prescriber's NPI, the patient's member ID, the drug name and strength, and the original denial reference number on every page. Lost paperwork is a real and common problem. * Document failure of alternatives with dates, doses, duration, and outcomes, not just "patient tried X." * Write clearly enough for a non-specialist to follow the logic, but include the clinical specifics that will matter if the case gets escalated. First-level reviewers often don't have clinical training. AI-powered appeal generators are showing up in more RCM workflows, and for high-volume practices managing appeals across multiple PBMs, they're worth evaluating. They can pull in appropriate clinical language and structure arguments more consistently than building each appeal from scratch. They're tools, not a substitute for knowing the underlying criteria. Getting smarter about PBM appeals in 2026. PBMs are adding prior authorization requirements, expanding formulary exclusions, and tightening clinical criteria. What cleared in 2024 may require substantially more documentation now. The practices that manage this well share one habit: they track denial reasons systematically by PBM, not just aggregate outcomes. That means knowing which drugs are being denied repeatedly at one PBM but not others, which criteria language keeps showing up, and which providers' documentation needs work before submission. Start by pulling your last 90 days of pharmacy denials and sorting by PBM. The patterns will be obvious, and they'll tell you exactly where to focus your time. Edward Krishtul is the founder of EZAppeal and a utilization management professional with years of experience in insurance denial review, medical necessity criteria, and clinical appeals. He built EZAppeal to help healthcare providers and billing companies generate payer-specific appeal letters backed by real clinical evidence - not generic templates. See EZAppeal work on a real denial. It drafts appeals and prior authorizations grounded in the payer's own published policy. BAA included, zero PHI stored. Try the live demo, no signup Compare AI appeal tools. #pharmacy #PBM #Caremark #Express Scripts #OptumRx #appeals