What Technologies Support Payers With Claims Management Processes?
HealthPayerIntelligence Claims management is an integral part of the healthcare process as it determines how much providers receive in reimbursement, what costs health plans will cover, and what patients ultimately owe for their care. After providing care, healthcare providers must code the services and submit a claim to the patient’s health insurance plan. Once they receive the claim, payers review and...
More Features
How to Evaluate Benefits to Ensure Health Equity for All Members
Although the healthcare system has made great strides in health equity awareness and promotion, women pay more and get less out of their employer-sponsored health benefits than men do. Employed women are more likely to hit their...
The Medicare Advantage Marketing Problem and Where It’s Headed
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
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
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 Do Payers Approach Care Management Strategies, Technologies?
An essential element of value-based care success is proper care management. Care management revolves around team-based, patient-centered strategies that work toward helping patients manage their medical conditions in a cost-effective way....
How the Top 4 Disruptive Insurtechs Have Evolved Since Their IPOs
The insurtechs that saw the greatest success after the start of the coronavirus pandemic have faced a tumultuous path since their initial public offerings (IPOs). In 2021, four insurtechs achieved their IPO. Their goal was to disrupt the...
Exploring the History of the Blue Cross Blue Shield Association
Blue Cross Blue Shield is an easily recognizable name in the healthcare industry, but just how many health plans fall under this organization and what are the differences between them? In the following article, HealthPayerIntelligence...
An Overview of the CMS AHEAD Model for Health Equity Advancement
The CMS States Advancing All-Payer Health Equity Approaches and Development Model (AHEAD Model) rallies states and a broad scope of healthcare stakeholders around health equity improvement through primary care investments and...
Employers Grapple with Workforce Mental Health Needs Post-Pandemic
Mental health has been a primary focus for employers following the peak of COVID-19. As the pandemic becomes more manageable, large employers are implementing strategies to address access to care, burnout, and quality of mental healthcare,...
How Can Medicare Advantage Organizations Prepare for RADV Audits?
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...
Key Strategies for Transitioning a Health Plan into Cloud Computing
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...
Unpacking What Price Transparency Looks Like for Health Plans
Consumers are struggling to understand and afford healthcare in the United States. A new federal requirement aimed at increasing healthcare price transparency aims to help, but payers can also use this newly available information to their...
How Payers Can Reduce Emergency Department Admission Rates, Costs
Members and payers do not always see eye-to-eye, but one point on which they closely align is their desire for members to stay out of the emergency department. Emergency department visits are associated with higher healthcare spending. A...
Top Member Education Strategies for High Performance Network Benefits
As payers and employers gravitate toward high performance networks, there is a demand for better member education around these plans’ benefits. Regulators have expressed concerns that high performance networks will limit...
4 Essential Components of Chronic Disease Management Strategies
With the US spending $3.7 trillion on diseases like diabetes, cancer, and other long-term conditions each year, payers cannot afford to falter on chronic disease management. Chronic disease spending and prevalence trends are stark, but...
How One MA Plan Prioritized SDOH to Improve Diabetes Care Access
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 diabetes....
First Impressions Count: How Onboarding Affects Member Engagement
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 a...
Value-Based Care and Fee-For-Service: What’s the Difference?
In an effort to improve care quality and lower costs, the healthcare industry has been working on shifting from fee-for-service to value-based care delivery. The two models differ in the way providers are reimbursed for the care they...
Common Utilization Measures That Impact Value-Based Care Efforts
Quality and quantity have a nuanced relationship in the healthcare system: put simply, payers want to reduce members’ quantity of low-value services while increasing the number of services that produce better quality...
