Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

HealthPayerIntelligence News

CMS to Audit Premium Subsidy Eligibility for Individual Health Plans

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CMS has proposed a new rule that would audit premium subsidy eligibility for individual health plan beneficiaries and monitor premium assistance programs through the federal insurance exchanges. The Patient Protection and Affordable Care...

US District Court Denies Appeal to Resolve Risk Corridor Payments

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Federal judges for the US Federal District Court of Appeals denied a request to reopen a case that could provide over $12 billion in risk corridor payments to payers. Moda Health Plan, BlueCross BlueShield of North Carolina, and Land of...

Employer-Sponsored Medicare Advantage Enrollment Up 12% for 2019

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Employer-sponsored Medicare Advantage (MA) enrollment for plan year 2019 increased by 12 percent, representing a bump of more than 443,000 individual members, according to a new analysis by Mark Farrah Associates. Individual Medicare...

Poor Data Quality in CA Medicaid Drives $4B in Improper Payments

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California's Medicaid program, Medi-Cal, made over $4 billion in improper payments to cover benefits for ineligible beneficiaries because of poor data quality and insufficient oversight, according to a new report from state...

Commercial, Managed Care Insurance Sectors Profits Boom in Q3

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Commercial and managed care payers experienced significant third quarter profits, reductions in healthcare spending, and enrollment growth, according to the latest financial statements from insurance companies. Medicare Advantage (MA),...

Retail Clinics, Surprise Bills Changing Healthcare Purchasing Patterns

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Consumers are changing the way they spend their healthcare dollars as the stress of surprise medical bills, coupled with new retail-style options, change the care delivery landscape. Two new consumer surveys reveal that changing...

BCBSAZ Shared Savings Program Reduces Hospital Readmissions by 26%

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BlueCross BlueShield of Arizona’s (BCBSAZ) shared savings program has reduced 30-day hospital readmission rates by 26.3 percent while generating shared savings for providers.. BCBSAZ also reported 15.2 percent fewer ED visits per...

CMS Redesigns Medicare Home Health Payment with Case Mix Model

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CMS has proposed a new rule that would recalculate Medicare home health payments using a case mix payment model.   In 2020, the agency plans to implement the Patient-Driven Groupings Model (PDGM) to compensate home health agencies...

Consumer Demand for High-Deductible Health Plans Dwindles

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Consumer demand for high-deductible health plans (HDHPs) is expected to decline in 2019 as more beneficiaries look for health plans with customized benefits instead, according to a new survey from Oliver Wyman. Half of consumers surveyed...

CMS Extends Medicare Advantage Audit Program in 2019 Rule

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CMS will be continuing its Medicare Advantage audit program, the agency indicated in a proposed 2019 rule, in an effort to ensure program integrity and reduce inappropriate payments to insurers. The changes are part of CMS’s new...

Can Payers Reduce Stress of Alternative Payment Models for Physicians?

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Alternative payment models (APMs) may be placing significant burdens and stress on physicians, requiring payers to make additional efforts to improve their communication and smooth the process of transitioning to value-based care,...

Cigna: Integrated Pharmacy, Medical Benefits Improve Overall Health

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Integrating pharmacy benefits with medical benefits can help to improve overall health and reduce employer costs, according to a new study released by Cigna. Individuals with connected medical, behavioral and pharmacy health benefits...

60% of Employers Fail to Address Healthcare Spending Waste

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Sixty percent of employers don’t capitalize on opportunities to address healthcare spending waste, even though they say wasteful spending is a key concern, according to a new survey from the National Alliance of Healthcare Purchaser...

CMS Grants NC 1115 Medicaid Waiver to Implement Managed Care System

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North Carolina has received a 1115 waiver from CMS allowing the state to implement a Medicaid managed care system administered through private payers. The state’s Department of Health and Human Services (DHHS) can now recruit...

New Drug Pricing Model Could Save Medicare Part B $17.2 Billion

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A new drug pricing model with an international component could save Medicare Part B approximately $17.2 billion over five years, CMS says.   The International Pricing Index (IPI) will test if using drug price benchmarks other...

PBMs, Specialized Formularies Reduce Managed Care Prescription Costs

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Pharmacy benefit managers (PBMs) with specialized drug formularies can help managed care payers significantly reduce prescription drug costs, according to new research published in the Journal of Managed Care and Speciality Pharmacy. The...

Venture-Funded Medicare Advantage Plans Launch into 2019 Market

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Several Medicare Advantage (MA) plans entering the market for the 2019 plan year are backed by millions in venture capital funding and are planning to compete with established payers by promoting new health plan solutions. The recent...

Engagement, Data Analytics Cut Opioid Dependency in Managed Care

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AmeriHealth Caritas has successfully reduced opioid dependency rates among managed care beneficiaries through member engagement and data analytics techniques that promote alternatives to opioid treatments. The payer’s Opioid...

Employer Wellness Programs Reduce Costs by Targeting Chronic Diseases

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In order to reduce overall spending, employers should focus on designing wellness programs that target chronic diseases and address other clinical factors impacting employee health, says a new research paper from Transamerica. The...

Proposed Rule Alters HRAs to Allow Direct Reimbursement to Employees

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The Departments of Labor, Treasury, and HHS have proposed a new rule that would allow employers to directly reimburse employees’ care costs through health reimbursement arrangements (HRAs) as an alternative to traditional insurance...

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