Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management

Social Determinant Data Key to Successful Risk-Based Contracts

February 28, 2017 - From bundled payment models to capitated healthcare payments, payers implement risk contracts to financially motivate providers to target high-cost and high-utilization patient populations to reduce overall healthcare costs. But increasing payer access to social determinant data is the key to creating more successful risk contracts, Jennifer Daley, MD, a Market Medical Executive at Cigna,...


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Social Determinant Data Key to Successful Risk-Based Contracts

by Jacqueline Belliveau

From bundled payment models to capitated healthcare payments, payers implement risk contracts to financially motivate providers to target high-cost and high-utilization patient populations to reduce overall healthcare costs. But increasing payer...

GAO: Erroneous Medicaid Claims Data Pose Fraud Risk at CMS

by Thomas Beaton

Millions of people rely on long-term personal care services under Medicaid coverage, but significant gaps and errors in two major CMS data systems are creating significant opportunities for fraud and abuse.   A new report from the Government...

Does Tiered Cost-Sharing Promote Appropriate Medication Use?

by Jacqueline Belliveau

Health plans have traditionally used tiered formulary cost-sharing arrangements to reduce healthcare spending and incentivize appropriate medication use. But a recent Journal of Managed Care & Specialty Pharmacy study found that stakeholders...

How Payers, Providers Could Streamline Medical Claims Management

by Vera Gruessner

Successful medical claims management and processing is not always easy to garner for health insurance companies due to a lack of training among insurance agents, missing or inaccurate documentation, and the general time-consuming aspect...

Key Ways Payers Could Improve Medical Claims Management

by Vera Gruessner

Medical claims management is a key aspect of the payer-provider relationship. However, medical claims management tends to include multiple challenges for both payers and providers. Some of the problems stem from a lack of training in medical...

How Provider Portals Streamline Medical Claims Management

by Vera Gruessner

Healthcare payers have often struggled to process claims and provide effective customer service in a more streamlined manner due to technological inefficiencies. Insurers have faced challenges with engaging both their consumer base as well as...

Why Health Insurance Claims Should Include Medical Device UDIs

by Vera Gruessner

More and more healthcare associations have been emphasizing the need to incorporate unique device identifiers (UDIs) from medical devices within health insurance claims. In fact, professionals from The Brookings Institution have spoken in favor...

Top 3 Ways Payers and Providers Can Reduce Claim Denials

by Vera Gruessner

When it comes to medical claims management, healthcare payers and providers will need to communicate more effectively so that both parties are on the same page when it comes to claim denials. Healthcare payers should know that communication is...

Does Reference Pricing Reduce Costs of Diagnostics for Payers?

by Vera Gruessner

Health insurers and consumers can benefit from seeking reference pricing when it comes to choosing specific diagnostic tests among a set of different laboratories. Researchers from the University of Southern California and the Brookings Institution...

Pediatric Care Out-of-Pocket Spending Rose 5.5% in 2014

by Vera Gruessner

Both public and private health payers have been searching for ways to reduce healthcare spending as a whole, but rising prices may be making it more difficult to combat medical care expenditure. The Health Care Cost Institute (HCCI) released...

Veterans Affairs Processes Only 66% of Claims in 30 Days

by Vera Gruessner

The Medicare program, Medicaid coverage, and the Children's Health Insurance Program are not the only public payers offering  assistance to the American people. Veterans Affairs (VA) also ensures that those in the military receive access...

13% of Midsize Employers Provide High-Deductible Health Plans

by Vera Gruessner

The health insurance industry has been changing due to the Affordable Care Act and other regulatory pressures from the Centers for Medicare & Medicaid Services (CMS). Rising healthcare costs along with the reforms taking place among payers...

Healthcare Cost Variation Differs Twofold between States

by Vera Gruessner

Those who have spent time in a doctor’s office or emergency room may have seen that the prices of healthcare services tend to vary drastically among separate medical facilities. New findings from the Health Care Cost Institute (HCCI) shows...

Risk Adjustment Affects Plans on Health Insurance Exchanges

by Vera Gruessner

The trade association AMGA, which entails a large membership of medical groups and healthcare delivery systems, submitted comments last week to the Centers for Medicare & Medicaid Services (CMS) regarding its proposal to change risk adjustment...

How Data, Value-Based Care Drives Down Health Insurance Costs

by Vera Gruessner

In today’s world, the average employee and business owner are seeing a rise in health insurance costs. Even through the health insurance exchange, premium prices are expected to rise this year while high-deductible plans are becoming more...

How One Health Payer Partnership Reduced Hospitalizations

by Vera Gruessner

Recently, the health payer Blue Cross and Blue Shield of Illinois (BCBSIL) announced in a press release that it will be extending its partnership with the American Lung Association of the Upper Midwest over the next two years. The specific partnership...

How Health IT Automation Improves Consumer Satisfaction

by Vera Gruessner

New technologies and health IT tools are becoming a necessary part of the health insurance industry, as innovative approaches like automation can largely benefit employees while portals could make a difference for health plan consumers. When...

How New Policies Impact Healthcare Spending and Access

by Vera Gruessner

The Health Care Cost Institute (HCCI) announced today the publication of six different policy briefs entailing how state and federal regulations are affecting healthcare spending and patient services. Independent researchers used HCCI’s...

Value-based Care Reimbursement Makes Strides in Health Plans

by Vera Gruessner

The fee-for-service payment model is slowly becoming an antiquated concept as more insurers and healthcare providers adopt value-based care reimbursement. Karen Ignani, President of Emblem Health and former CEO of America’s Health Insurance...

52% of Employers Offer High-Deductible Health Insurance Plans

by Vera Gruessner

Despite the fact that the health insurance exchanges and Medicaid expansion opened up more opportunities for Americans to obtain healthcare coverage without being dependent on employment, the health payer industry is still intertwined with the...

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