Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management

Stop-Loss Insurance a Growing Market Opportunity for Healthcare

August 18, 2017 - Even though payers may experience higher total revenues on commercial self-insurance, stop-loss and third-party protected insurance revenues have been growing at a higher rate with stronger market stability according to market research from AM Best. Unlike reinsurance, a market stabilization program where self-insured payers contribute funds to protect health plans from premium increases,...


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How Can Health Savings Accounts Help, Hinder Patients and Payers?

by Thomas Beaton

Health savings accounts (HSAs) have been widely discussed as lawmakers consider policy reforms, at the federal level, and have become a fixture in conversations about healthcare spending among payers and patients alike.   HSAs are consumer...

What to Look for in Health Insurance Enrollment Technology

by Thomas Beaton

Health insurance enrollment technology is designed to offer payers convenience, cost savings, and administrative ease-of-mind when it comes managing beneficiaries enrolled in health plans. Many Americans face challenges when seeking new health...

Texas Wrongly Claimed $3.8M in Medicaid Reimbursements

by Thomas Beaton

Texas’s Department of Health and Human Services failed to adhere to federal guidelines and inappropriately claimed $3.8 million in Medicaid managed care reimbursement.    The Office of Inspector General (OIG) recently published...

ACA Risk Adjustment, Reinsurance Improved Payer Financials

by Thomas Beaton

A new study published in Health Affairs found risk adjustment and reinsurance provisions of the Affordable Care Act improved financial outcomes for certain payers with higher risk enrollees.   Researchers from AHRQ and CMS found that before...

BCBS of Minn. Cites Risk Pools for $322.4M in 2016 Losses

by Thomas Beaton

Blue Cross Blue Shield (BCBS) of Minnesota reported a net operating loss of $322.4 million in their 2016 financial audit, citing unbalanced risk pools and rising premium pricing as a current and future detriment to profitability. At the end of...

WI Improperly Claimed $3M in Medicaid Drug Reimbursement

by Thomas Beaton

Wisconsin’s Department of Health Services failed to correctly invoice providers for over $3 million in Medicaid drug reimbursement, says the Office of the Inspector General (OIG) in a new report, leading to improper reimbursement from federal...

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...

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