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HealthPayerIntelligence News

Managed Care Payers Struggle to Staff Long Term Support Services

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Managed care payers and state Medicaid agencies are finding it difficult to find personnel to administer long-term support services (LTSS) within home and community-based settings (HCBS), says a new GAO report. Currently, Medicaid spends...

How Payers Can Develop a Medication Therapy Management Program

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As the cost of medication non-adherence reaches over $300 billion annually, payers are increasingly challenged to provide new solutions to address the healthcare and economic impacts of non-adherence. Payers could develop a medication...

Payers Can Leverage Telehealth for Chronic Disease Management

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Telehealth offers a cost-effective way to improve member satisfaction with benefits and support meaningful chronic disease management, according to a new report from AHIP and the Coalition to Transform Advanced Care (C-TAC)....

DaVita Medical to Pay $270M for Improper Medicare Advantage Payments

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DaVita Medical Group has agreed to pay $270 million to the Medicare program after identifying suspect billing practices that incorrectly raised its Medicare Advantage payments, says the Department of Justice (DOJ). The improper MA...

Cigna’s Digital Diabetes Prevention Program Cuts Costs, Ups Outcomes

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With more than one out of every three Americans living with prediabetes, payers are actively seeking out innovative strategies for preventing progression of the costly and life-changing disease.   Most payers offer clinical benefits...

How Managed Care Payers Can Improve Substance Use Treatment

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Managed care payers can use data analytics, case management strategies, and patient engagement tools to address the needs of high-risk individuals with substance use disorders (SUDs), states a new report from the Association for Community...

OIG Finds Profits to Blame for Denied Medicare Advantage Claims

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Fifty-six percent of Medicare Advantage (MA) payers inappropriately denied claims from beneficiaries and providers to potentially profit from the capitated payment system, according to a report from the Office of Inspector General...

Medicare Advantage Premiums to Decrease by 6% in 2019

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CMS officially announced a six-percent decrease in Medicare Advantage premiums in 2019 as the result of MA enrollment, health plan options, and benefits increase. All signs point to the MA marketplace continuing to be a lucrative...

NYCHH Triples Denials Recovery from UnitedHealthcare to $40.1M

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NYC Health + Hospitals (NYCHH) has more than tripled the amount the health system is seeking in claims recovery from UnitedHealthcare, from $11.1 million to $40.1 million after a comprehensive case-by-case review of high-profile...

Aetna Sells Portion of Medicare Business to Fast-Track CVS-Aetna

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Aetna has sold its Medicare Part D prescription plan business of 2.2 million beneficiaries to WellCare in an attempt to increase the likelihood of the CVS-Aetna merger closing before year’s end. In SEC filings, Aetna explained that...

Consumer Engagement Tools Prep Members for Open Enrollment

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Mobile apps, enrollment platforms, and search engines help the majority of consumers prepare for open enrollment and make informed healthcare choices, says a new survey from UnitedHealthcare. Thirty-six percent of consumers said they used...

Employers are Experimenting with Innovative Health Plan Designs

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Just under half of employers participating in a survey from the National Business Group on Health (NBGH) are actively experimenting with innovative health plan designs that aim to foster new approaches to care delivery. NBGH found that...

NCQA, Health Plans to Measure Patient-Reported Outcomes

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The National Committee for Quality Assurance (NCQA) has selected four health plans to test a new performance standard for collecting patient-reported outcomes measures, or PROMs. NCQA’s Person-Driven Outcome Measurement...

31% of Beneficiaries Face Social Isolation, More Health Risks

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A new survey of Humana’s commercial population has found that almost one-third of members over 65 years old experience social isolation. The survey reveals that payers could benefit by addressing social isolation among their elderly...

Montana Reinsurance Program May Cut Premiums Up to 20%

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Montana is moving ahead with the idea of creating a reinsurance program for the state’s health insurance market.  The program may reduce premiums between 10 and 20 percent, said Governor Steve Bullock and Department of...

Top Health Plans Excel in Preventive Care, Chronic Disease Management

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Health plans that offered high-quality preventive care and comprehensive chronic disease management received top marks in the latest health plan rankings from the National Committee on Quality Assurance (NCQA). NCQA ranks health plans in...

Narrow Network Alignment Could Drive Value-Based Payment Reform

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Investment in high-performance narrow networks, creating new payment incentives, and leveraging digital innovation could help to increase adoption of value-based payment reform across the healthcare industry, say experts in a New England...

Risk Scoring, New Payment Models Can Reduce Medication Non-Adherence

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Adopting new payment models, engaging in targeted risk scoring, and improving prior authorization processes may help payers address medication-non adherence among members with mental health concerns, says a report from the National Council...

Senators Propose Limits on Surprise Healthcare Billing

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A bipartisan group of Senators has introduced legislation that aims to end surprise healthcare billing, a practice which can lead to extremely high out-of-pocket costs for consumers. The Protecting Patients from Surprise Medical Bills Act...

Payers Play Crucial Role in Healthcare Quality Transparency

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Payers will need to take the lead in being transparent about healthcare quality and costs in order to improve patient safety and reduce unnecessary spending, experts told the Senate HELP Committee. Payers can take a more proactive role in...

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