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PHE unwinding work may aid Medicaid, CHIP final rule compliance

April 11, 2024 - 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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With Proper Use, Artificial Intelligence Improves Health Plan Operations

by Victoria Bailey

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...

What Is Behind Rampant Medicare Advantage Contract Terminations?

by Victoria Bailey

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...

How One Payer Tackled the No Surprises Act Provider Directory Rule

by Kelsey Waddill

Brian Marsella, president of Health Payment Systems (HPS) and Paymedix, was accustomed to the challenges of maintaining provider directories when he joined HPS and Paymedix in 2022. But two years into...

2024 Payer Strategies: Population-Based Plans, MA Differentiation

by Kelsey Waddill

The new year may look remarkably like 2023 from the payer perspective with a similar set of headwinds, but payer strategies may change. Health insurers will build on last year’s progress in...

How Healthcare Leaders Can Weigh Pros, Cons of Payer Megamergers

by Kelsey Waddill

When rumors circulate about major payers planning to merge, it always stokes the question: are payer megamergers ultimately good for the healthcare system? When the news broke that Cigna and Humana...

Blue Cross Blue Shield of MA Eliminates More Prior Authorizations

by Kelsey Waddill

Blue Cross Blue Shield of Massachusetts (“Blue Cross”) joined other payers in eradicating prior authorizations for certain services as part of an effort to accelerate members’ access...

3 Steps One Medicaid MCO Took to Boost Its Patient Experience Score

by Kelsey Waddill

Ease and efficiency in access to care contribute to the patient experience measurement in the National Committee on Quality Assurance’s (NCQA) Health Plan Report Card for Medicaid managed care...

What Cigna’s FCA Settlement Means for Other Medicare Advantage Plans

by Victoria Bailey

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...

The Medicare Advantage Marketing Problem and Where It’s Headed

by Victoria Bailey

Each year, Medicare’s open enrollment period starts mid-October and is preceded by an influx of marketing materials advertising private Medicare Advantage, Medicare Part D, and Medigap plans. While marketing practices are intended to...

Medicare Advantage RADV Rule May Prompt More Legal Action from Payers

by Victoria Bailey

Payers have not reacted lightly to the Medicare Advantage Risk Adjustment Data Validation (RADV) final rule. Major payer Humana made the strongest display of disapproval by filing a lawsuit against CMS that seeks to invalidate the...

Top Reasons Behind Retail, Medicare Advantage Plan Partnerships

by Kelsey Waddill

Payers such as UnitedHealthcare, Priority Health, and Anthem have pursued Medicare Advantage plan partnerships with retail companies. What is the attraction to this type of partnership? Plans that are co-branded with retail companies are...

How Can Medicare Advantage Organizations Prepare for RADV Audits?

by Victoria Bailey

Increasing internal audits and implementing additional coding oversight can benefit Medicare Advantage organizations as they manage new auditing regulations, Melissa James, senior consultant at Wolters Kluwer, told...

Payer Turns to PBM Coupon Program to Lower Prescription Drug Spending

by Kelsey Waddill

Reducing drug prices is top-of-mind for payers and employers alike. Some payers, like Capital Blue Cross, seek to make drugs more affordable by connecting members with existing coupon...

Key Strategies for Transitioning a Health Plan into Cloud Computing

by Kelsey Waddill

Updated 08/14/2023: This article has been updated to reflect a few timeline discrepancies. Additionally, Lisa Davis's position was formerly listed as "senior vice president," which was her role when she was hired at Blue...

How One MA Plan Prioritized SDOH to Improve Diabetes Care Access

by Victoria Bailey

Health plans must look beyond clinical outcomes and address social determinants of health to improve beneficiaries’ health. Zing Health, an Illinois-based Medicare Advantage plan, did just that for beneficiaries living with...

First Impressions Count: How Onboarding Affects Member Engagement

by Kelsey Waddill

According to Christopher Lis, managing director of global healthcare intelligence at JD Power, if payers refined their onboarding processes, it could reform payers’ track record on health plan satisfaction. Specifically, he promoted...

How Long-Term Health Plan Enrollment Supports Value-Based Care

by Victoria Bailey

Realizing value-based care success is easier said than done. While a primary goal of value-based care is to improve long-term health outcomes and costs, that can be difficult when consumers’ healthcare journeys are disrupted each...

Slow but Steady: Experts Report on 2023 Mergers and Acquisitions Trends

by Kelsey Waddill

What will happen to the volume and value of mergers and acquisitions in 2023? This is a question at the forefront of payers’ minds as the healthcare industry emerges from the uncertainties of the coronavirus pandemic. The twelve...

Improve Coverage, Health Equity By Diversifying Broker Recruitment

by Kelsey Waddill

When Access Health CT (AHCT), Connecticut’s marketplace, published its health equity report, leaders of the state health insurance marketplace knew that something needed to change. In a state that ranks among the healthiest and...

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