Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payers

Humana, Walgreens Offer Primary Care Clinics for Medicare Members

June 21, 2018 - 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 subsidiary called Partners in Primary Care, will launch the clinics in the fall of 2018.  The clinics specialize in integration of primary, pharmacy, and...


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Beneficiaries Want More Holistic Health, Wellness Benefit Options

by Thomas Beaton

Health plan beneficiaries are increasing their demand for holistic health and wellness benefits, which can help payers deliver value and improve outcomes, according to a new report from Aetna. The Health Ambitions Study found that beneficiaries...

Amazon, Berkshire, JPMorgan Name Atul Gawande Healthcare CEO

by Thomas Beaton

Amazon, Berkshire Hathaway, and JPMorgan Chase have named Atul Gawande, a surgeon at Brigham & Women’s Hospital, as the CEO of their joint healthcare company. The company will be headquartered in Boston, Massachusetts. Gawande will...

Customer Service is Primary Driver of Health Plan Satisfaction

by Thomas Beaton

Health plan members are seeking high-quality customer service experiences from their insurers, and will use positive interactions to make decisions about continued loyalty, according to a new Forrester analysis emailed to members of the press....

Department of Labor Finalizes Association Health Plan Expansion

by Thomas Beaton

The Department of Labor (DOL) has issued a final rule that expands consumer availability of association health plans (AHPs) starting on September 1, 2018. The rule comes months after President Trump and the DOL proposed executive changes that...

US Court: Payers Are Responsible for Risk Corridor Program Costs

by Thomas Beaton

Federal judges in the US Federal Circuit Court of Appeals have issued an opinion stating that healthcare payers, and not HHS, are responsible for the costs of the ACA’s risk corridor program. Chief Judge Sharon Prost filed the majority...

BlueCross BlueShield Nets $2.3B in Savings from 2017 Tax Cuts

by Thomas Beaton

BlueCross BlueShield companies saw  a total tax savings of $2.3 billion after passage of last year’s Tax Cuts and Jobs Act (TCJA), according to a new creditor’s briefing from AM Best. BCBS companies reported a mix of gains and...

Automated Claims Administration Could Bring Billions in Savings

by Thomas Beaton

Automated claims administration could bring around $11 billion in savings to health plans and providers if the technology is implemented more broadly, according to the latest CAQH Index. Payers should encourage providers to adopt technologies...

Quality Analytics, Risk Adjustment Tools Prep Payers for Success

by Thomas Beaton

Quality analytics and risk adjustment technologies are effective solutions for payers when these tools can structure claims and clinical information into actionable models, identify multiple risk indicators, and foster provider collaboration,...

Humana, Roche Diagnostics Face $45M Federal Kickback Lawsuit

by Thomas Beaton

Humana and Roche Diagnostics will face a $45 million federal kickback lawsuit after a whistleblower filed a False Claims Act violation, which alleges Roche tried to entice Humana financially to secure access to the payer’s business operations....

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 access...

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 memo...

Early Health Insurance Premium Proposals Indicate Hikes for 2019

by Thomas Beaton

Significant increases to health insurance premiums are on the horizon for beneficiaries in multiple states as payers begin to share their 2019 rate plans.   A challenging regulatory landscape, complicated by policy changes that have altered...

Virginia Legislature Approves Medicaid Expansion

by Thomas Beaton

The Virginia General Assembly has passed Medicaid expansion as part of a two-year budget bill that could provide coverage to 400,000 newly eligible residents. The action would make Virginia the 33rd state in the US to expand Medicaid under the...

MSSP ACOs Taking on Downside Risk See Smaller Savings

by Thomas Beaton

Medicare Shared Savings Program (MSSP) ACOs that take on downside risk generate smaller savings than upside risk ACOs, according a Center for Healthcare Quality and Payment Reform (CHQPR) analysis. In 2016, the average annual cost of care per...

WellCare Buys Meridian for $2.5B to Grow Medicaid Footprint

by Thomas Beaton

WellCare has entered into a definitive agreement to purchase Meridian Health Plan of Michigan, Meridian Health Plan of Illinois, and MeridianRx in order to increase revenues and expand its footprint in the Medicaid and Medicare Advantage markets....

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 boroughs,...

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, it...

How Payers Identify, Succeed in Health Plan Market Opportunities

by Thomas Beaton

Healthcare payers that wish to be known as innovators need to continually be on the lookout for emerging health plan market opportunities that offer strong profit potential. Payers need to monitor specific market indicators and implement new...

MN Law Allows Some Patients to Override Payers on Step Therapy

by Thomas Beaton

Minnesota Governor Mark Dayton has signed a bill into law that allows patients and providers to execute overrides on payer step therapy programs for prescription drug treatments in certain clinical situations. HF 3196 requires payers to bypass...

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