Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Costs

Emergency Physician Group Sues Anthem for ED Payment Policies

July 18, 2018 - The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) have filed a lawsuit against Anthem BCBS of Georgia contesting an emergency department payment policy that makes patients responsible for covering non-emergency expenses. The lawsuit, filed in the District Court of Northern Georgia, contends that Anthem’s policy to retroactively deny...

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High Dollar Claims Rise by 87% in Employer-Sponsored Stop-Loss Insurance

by Thomas Beaton

The number of employer-sponsored stop-loss insurance claims of $1 million or more grew by 87 percent from 2014 to 2017, according to a new analysis from Sun Life Financial. Over the four-year period, 634 employees with $1 million claims cos...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Health Plan Cost Sharing, Deductibles Outpace Members’ Wage Growth

by Thomas Beaton

Health plan cost sharing and deductible spending have outpaced employee wage growth in the last ten years, according to data released by the Peterson-Kaiser Health System Tracker. Employees’ total financial responsibility increased by...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

CMS Suspends $10.4B in Risk Adjustment Payments to Payers

by Thomas Beaton

CMS has temporarily withheld $10.4 billion in risk adjustment payments for 654 healthcare payers, citing a ruling in the US District Court of New Mexico that invalidated the agency’s risk adjustment methodology. The ruling, which took...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Medicare, Medicaid Home Health Benefits Stabilize Care Costs

by Thomas Beaton

Providing extended home health benefits for Medicare beneficiaries is likely to stabilize care costs for public payer programs, according to a new analysis from the Commonwealth Fund. Researchers from the Hilltop Institute and Johns Hopkins...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Highmark BCBS Saves $260M Using Value-Based Reimbursement

by Thomas Beaton

Highmark BlueCross BlueShield has saved $260 million in avoidable care costs by using value-based reimbursement and provider performance standards to hold healthcare organizations accountable for improving beneficiary outcomes. Highmark&rsq...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Can Retail Clinics Improve Patient Access, Reduce Costs for Payers?

by Thomas Beaton

Retail clinics are gaining in popularity among patients looking for quick, convenient care for minor ailments. Kiosks and no-appointment-needed offices located in corner pharmacies and big box stores have the potential to keep patients out ...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Partners HealthCare to Self-Insure 100K Employees

by Thomas Beaton

Partners HealthCare has announced it will self-insure 100,000 of its employees, transitioning coverage from BlueCross BlueShield of Massachusetts to its own Neighborhood Health Plan, according to The Boston Globe. “Neighborhood Health...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

MedPAC: Value-Based Payment, Post-Acute Care Boost Medicare Savings

by Thomas Beaton

MedPAC has advised Congress that value-based payment reform and encouraging the use of post-acute care can help the Medicare program increase savings and improve beneficiary outcomes, the group said in a new report. Revisions to payment met...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Narrow Networks, Customer Satisfaction Contain Payer Spending

by Thomas Beaton

Payers can curb spending on medical care by investing in narrow networks and customer satisfaction tools, says a new PricewaterhouseCoopers (PwC) Health Research Institute (HRI) analysis. PwC found that medical costs for employer-sponsored ...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Humana, Walgreens Offer Primary Care Clinics for Medicare Members

by Thomas Beaton

Humana and Walgreens have announced the launch of two primary care clinics, designed to meet the needs of Medicare beneficiaries, that will operate within Walgreens locations in the Kansas City area. The collaboration, led by a Humana subsi...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Value-Based Payment Adoption Drives 5.6% Reduction in Care Costs

by Thomas Beaton

Payers that implemented value-based payment models reduced healthcare costs by an average of 5.6 percent, improved provider collaboration, and created more impactful member engagement, according to a new study from Change Healthcare. The Fi...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Private Payers Deny Hepatitis C Drug Coverage to 52% of Members

by Thomas Beaton

Private payers denied Hepatitis C drug coverage to 52.4 percent of commercially insured beneficiaries from 2014 to 2017, according to new research from the Perelman School of Medicine at the University of Pennsylvania. Hepatitis C drug acce...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

AHIP, BCBSA, AMA Join to Improve Public, Private Payer Ecosystem

by Thomas Beaton

The Partnership for America’s Health Care Future (PAHCF), a newly formed coalition, consisting of leading healthcare provider societies and payer organizations, has committed to strengthening the nation’s private and public paye...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

BCBS of TX Delays Non-Emergency ED Claims Review Policy

by Thomas Beaton

BlueCross BlueShield of Texas has delayed implementation of a claims review policy that would require HMO members to pay the total cost of an emergency department visit if the encounter is later deemed to be a non-emergency, according to a ...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Helping Payers Implement Value-Based Hospital Reimbursement

by Thomas Beaton

Hospitals generate some of the largest revenues and create exceptionally high costs for payers, which combine open the possibility for value-based hospital reimbursement programs to control spending.        In March 2018...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Amazon, Berkshire Hathaway, JP Morgan to Name Healthcare CEO

by Thomas Beaton

The new Amazon, Berkshire Hathaway, and JP Morgan & Chase healthcare company will have its inaugural CEO in the next two weeks, Berkshire Hathaway’s CEO Warren Buffett told CNBC in an interview. Buffett was joined by Jam...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

Unstable Future Predicted for Medicare, Depletion by 2026

by Thomas Beaton

The Medicare Board of Trustees (MBT)’s latest report anticipates that Medicare’s Hospital Insurance (HI) Trust Fund will deplete by the year 2026 as Medicare spending continues to outgrow the trust’s collective revenues. T...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

NYCHH Seeks $11.5M from UnitedHealthcare for Denied Claims

by Thomas Beaton

A New-York based health system has initiated arbitration with UnitedHealthcare in order to collect $11.5 million in denied reimbursement from claims. NYC Health + Hospitals, a public healthcare network that serves New York City’s five...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}

How Can Payers Get Providers to Use Electronic Payment Systems?

by Thomas Beaton

Healthcare, an industry that lags behind others in technology adoption, is slow to embrace innovative solutions that address business challenges. For payers that want to implement electronic payment systems to improve claims reimbursement, ...{copy_healthpi}{content}{/copy_healthpi}{/article_body_blocks}


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