PHE unwinding work may aid Medicaid, CHIP final rule compliance
HealthPayerIntelligence The eligibility and enrollment processes for Medicaid and the Children’s Health Insurance Program (CHIP) have been riddled with inefficiencies. Policies like annual coverage limits and waiting periods have created barriers for low-income adults and children seeking coverage through the public programs. The Biden administration aims to address these issues in the Streamlining the...
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How are Medicare plans lowering drug costs for beneficiaries?
Affordable access to prescription drugs is a necessity for managing chronic and acute conditions and staying healthy. However, as drug costs rise, both affordability and accessibility are dwindling. Over 80 percent of surveyed adults said...
How can payers be prepared to manage third-party security incidents?
Security breaches and cyberattacks occur in the healthcare space at alarming rates, creating privacy concerns for all stakeholders involved. While provider organizations are the most common entities in healthcare that experience a security...
With Proper Use, Artificial Intelligence Improves Health Plan Operations
While artificial intelligence is far from a new concept, the healthcare industry has recently latched on to the technology, leading to increased adoption across many sectors. Artificial intelligence has the potential to lower healthcare...
How Payers and Pharmacy Benefit Managers Work Together to Lower Costs
As prescription drug spending rises in the United States, healthcare stakeholders and policymakers constantly look for ways to curb costs. Many payers turn to pharmacy benefit managers (PBMs), which aim to negotiate lower drug prices with...
Overcoming Tech Barriers to Achieve Prior Authorization Transparency
Prior authorization has posed problems for nearly all healthcare stakeholders. The CMS Interoperability and Prior Authorization Final Rule aims to streamline the utilization management process and improve data-sharing between payers,...
What Is Behind Rampant Medicare Advantage Contract Terminations?
With a history of overpayments, care denials, and limited provider networks, the relationship between Medicare Advantage and the rest of the healthcare industry has always been tumultuous. Over the past year, the private payer program has...
A Look Inside the Four Most Common Value-Based Care Arrangements
A simple explanation of value-based care is rewarding quality over quantity. However, value-based care arrangements differ in how they determine payments and the level of risk that is assumed. As healthcare organizations warm up to the idea...
What Utilization Management Strategies Do Payers Use to Lower Costs?
As healthcare spending rises in the United States, stakeholders are constantly working to address the drivers of high costs. The overutilization of healthcare services—including the provision of low- or no-value care—not only...
Key Regulations and Policies That Will Impact Payers in 2024
As healthcare stakeholders and the federal government work to make healthcare more accessible and affordable for consumers, CMS and HHS are frequently introducing and finalizing new rules and regulations. There were a couple of key policies...
What Health Plans Are Available For People With Disabilities?
Public and private payers alike offer a multitude of benefits for people living with disabilities. According to the CDC, up to 27 percent of adults in the United States have some type of disability, including mobility, cognition,...
How Do Payers Cover Prenatal, Postpartum Care for Pregnant People?
Prenatal, perinatal, and postpartum care help ensure healthier pregnancies and better birth outcomes for pregnant people. Access to this essential care comes easier with adequate health insurance. Pregnant people are almost guaranteed...
Understanding Chronic Kidney Disease Coverage, VBC Opportunities
Efforts to improve chronic kidney disease coverage have evolved over the last several decades, but the disease remains costly and prevalent. Around 15 percent of the adult population in the US has chronic kidney disease (CKD), according to...
How Can Payers Support Providers Through Workforce Challenges?
Although they likely existed before, the COVID-19 pandemic both highlighted and exacerbated workforce challenges among healthcare providers. Providers have implored federal leaders and agencies to increase support and resources as they...
How Public, Private Payers Cover Care for the LGBTQ+ Population
In a country with rampant health disparities, health insurance coverage can be the difference between accessing necessary services and going without care. How health plans cover care for socially disadvantaged and vulnerable populations can...
Top Payer Concerns, Opportunities Around Generative AI Integration
Generative AI may become a fixture of the health insurance landscape, seamlessly integrated into common payer processes, reducing timelines from hours or days to minutes. But for now, the tool’s future is fraught with challenges. Care...
4 Key Strategies to Promote Effective Payer, Provider Alignment
Strong payer-provider alignment makes life easier for all healthcare stakeholders. While providers administer services to individuals, payers are responsible for reimbursing providers and ensuring members have coverage for their care....
What Cigna’s FCA Settlement Means for Other Medicare Advantage Plans
Cigna’s recent brush with False Claims Act violations serves as a reminder that Medicare Advantage organizations should be routinely assessing their risk and compliance activities. The Department of Justice (DOJ) announced in...
Demystifying Medicaid Managed Care, Its Role in the Future of VBC
As the US healthcare system slowly transitions to value-based care, Medicaid managed care organizations are joining the movement by promoting capitated payment models and quality-based assessments. California was the first state to test out...
3 Ways That Large Employers Influence Health Insurance Costs, Coverage
Traditionally, health insurance companies have been the face of the payer industry, for better or for worse. But companies have incredible sway in the health insurance world, particularly large employers. Employers offer and manage...
