Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payers

Medicare Advantage Part B Plans Can Use Drug Step Therapy

August 13, 2018 - CMS is allowing Medicare Advantage (MA) health plans to implement step therapy protocols in order to decrease prescription drug spending. On January 1, 2019, MA health plans can apply step therapy guidelines for physician-administered medications. Step therapy requires beneficiaries to use condition-based prefered medications before using more expensive drugs. MA plans can also...


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AMA: CVS-Aetna Merger Would Reduce PBM Competition, Raise Prices

by Jennifer Bresnick

The American Medical Association is urging the Department of Justice to squash the proposed merger between CVS Health and Aetna.  The combined entity would drastically reduce competition in many pharmacy benefit management (PBM)...

Only 22% of Medicare Advantage Customers Aware of Star Ratings

by Thomas Beaton

Only 22 percent of Medicare Advantage (MA) beneficiaries are familiar with how star ratings work and increasing consumer awareness about star ratings would help beneficiaries choose high quality plans, according to a new Healthmine...

Provider Market Concentration Outweighs Payer Concentration

by Thomas Beaton

Healthcare provider systems tend to be bigger, more consolidated, and have more market share than payers in the same metropolitan areas, leaving some payers with less power to negotiate pricing and other contracts, according to the...

Centene, Ascension Partner for Medicare Advantage Offering

by Thomas Beaton

Centene and Ascension have partnered to offer a Medicare Advantage plan across multiple geographic markets in 2020.   Centene Chairman and CEO Michael F. Neidorff believes that the partnership will showcase effective strategies to...

CAQH CORE Urges Industry Collaboration on Prior Authorizations

by Thomas Beaton

CAQH CORE is urging healthcare payers, providers, and other stakeholders to promote industry-wide collaboration on how to improve prior authorizations. Leading provider and payer organizations, including AHIP, AHA, the BlueCross...

CMS: We Will Make $10.4B in 2017 Risk-Adjustment Payments

by Thomas Beaton

CMS has issued a final rule that will allow the agency to disburse $10 billion in 2017 risk adjustment payments that had been in doubt due to a court ruling.   To comply with the initial outcome of a New Mexico lawsuit contending the...

About 90% of Large, Mid-Size Employers Offer Medical Benefits

by Thomas Beaton

Close to 90 percent of employees in large and mid-size private businesses are offered medical benefits, according to data released by the Bureau of Labor Statistics. Larger businesses tend to see higher participation in employer-sponsored...

How Do Medicare Advantage, Medicare Supplemental Insurance Differ?

by Thomas Beaton

Medicare Advantage (MA) and Medicare supplemental insurance, or Medigap, are both intended to enhance the value of traditional Medicare coverage for seniors and other eligible beneficiaries. Both offer payers a lucrative opportunity to...

Pros and Cons of Small Business Health Options Program Health Plans

by Thomas Beaton

Health plans offered through the Small Business Health Options Program (SHOP) exchanges allow payers to provide the nation’s smallest businesses with affordable plan options that offer critical health benefits. SHOP health plans...

Emergency Physician Group Sues Anthem for ED Payment Policies

by Thomas Beaton

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...

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...

BCBSA Adds Opioid Abuse Accreditation to Treatment Facilities

by Thomas Beaton

The BlueCross BlueShield Association has announced a new accreditation program for opioid abuse treatment centers as a larger part of the organization’s mission to combat the US opioid crisis. In 2013, only 22 percent of treatment...

Medicare Advantage Savings, Outcomes Exceed Fee-For-Service

by Thomas Beaton

The Medicare Advantage (MA) program has surpassed Medicare fee-for-service (FFS) in developing positive member healthcare outcomes and reducing care costs, according to an analysis of both programs from Avalere Health. Medicare Advantage...

Medicare Advantage Star Ratings Tied to Member Socioeconomic Strata

by Thomas Beaton

Medicare Advantage (MA) health plans with a greater proportion of socioeconomically challenged members are more likely to have lower star ratings, according to new research from Brown University. Insufficient risk adjustment criteria in...

Transitional Health Insurance Plays Key Role in Coverage

by Thomas Beaton

Transitional health insurance, otherwise known as a short-term health plan, is a temporary insurance policy intended to provide stop-gap coverage when an individual is in between ACA compliant policies.  The National Association of...

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...

NCQA Updates, Adds HEDIS Performance Measures for Plan Year 2019

by Thomas Beaton

The National Committee for Quality Assurance (NCQA) has released updates to its HEDIS performance measures for plan year 2019. The refresh includes several new measures to guide population health management initiatives, as well....

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...

Aetna Takes Amerigroup Spot in Kansas Managed Medicaid Contract

by Thomas Beaton

Aetna has received a Managed Medicaid contract from the state of Kansas for plan year 2019 and will replace Amerigroup as one of the state’s three managed care payers. The state received six bids from commercial payers and...

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