Streamlining Claims Management

Effective payer provider collaboration is key to reducing the cost of healthcare, and claims management is an integral component of that relationship. As many organizations focus on care management, they must also streamline claims management processes to evolve with changing reimbursement models. Training and new technologies are at the core of claims management improvement. Technology […]

CEO Insight: Healthcare Trends to Watch

The healthcare payer landscape changes almost daily and it can be hard to see the forest through the proverbial trees. It’s easy to get focused on the day to day and miss important trends that may have significant impact down the road. As we look to the future, it’s important to keep these key trends […]

Core System Replacement Considerations for Healthcare Payers

New payment methods, accountable care, consumerism and an increasing demand for effective subscriber engagement and management (which disrupts traditional operating models in the small to mid-sized payer market) are placing enormous pressure on providers to innovate and improve operational efficiency. Outdated core legacy systems may hinder a payer’s ability to respond rapidly to this evolving […]

CEO Insight: Obstacle or Opportunity? Three hurdles facing healthcare payers

These are challenging times for healthcare payers. Increasing aging populations, pressure to cut costs, and a focus on quality is requiring everyone to do more with less. By facing these challenges head-on, we can turn these obstacles into opportunity. It is through continued innovation and experimentation that we will improve health care delivery in this […]

Automation can help commercial healthcare payers and providers save over $11 billion annually

Although the healthcare industry has made some progress in automating claims-related business processes, new findings in the 5th Annual CAQH Index show that widespread adoption of automation processes can result in huge cost savings. The index suggests that full adoption of electronic transactions in the healthcare industry will result in potential savings of over $11 […]

Understanding the Next Generation ACO Model

Accountable care organizations (ACOs) were designed to shift the healthcare industry from the fee-for-service payment model to value-based care, but haven’t always achieved their intended objectives. Based on the successes and limitations of the Medicare Shared Savings Program (MSSP) and the Pioneer ACO Model, CMS launched the Next Generation ACO (NGACO) Model in 2016 to […]

What you need to know about miscalculated 2019 MIPS payment adjustments

If you are one of the over 418,000 Medicare providers who participated in the 2017 MIPS reporting period, you may want to take a second look at your final score. CMS recently shared an important update announcing the extended deadline for clinicians, groups, and APM entities to review their performance feedback. Now you will have […]

What is the Health Insurance Providers Fee and Who Pays It?

To offset the growing number of uninsured Americans, Congress enacted the Affordable Care Act (ACA) in 2010. With it came provision 9010, establishing the Health Insurance Providers (HIP) fee, a tax that is placed on covered entities that provide health insurance. The intention of this fee was to help fund state marketplaces and exchanges, and […]

The Evolution of Data, Social Determinants, and AI in Population Health Management

Population Health Management is the new foundation in the successful shift to value-based care and is evolving beyond risk management. It’s currently focused on understanding who the most vulnerable of our patients are, but true Population Health Management necessitates a more thorough collection of patient data across all spectrums and an in-depth analysis of that […]

Medicare Beneficiary Identifier (MBI) to Replace HICN – What You Need to Know

The Medicare system is set to undergo a drastic change. Starting in the spring of 2018, all Medicare beneficiaries will be transitioning to a new identification system. As part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), this transition is designed to protect millions of Medicare beneficiaries. Through MACRA, beneficiaries will now […]