Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payers

IL Payers File Pharma Lawsuit Over Opioid Prescription Costs, Safety

October 17, 2018 - A coalition of Illinois payers has sued prominent pharmaceutical companies in a lawsuit that argues the companies are responsible for a spike in opioid prescription costs and patient safety risks. The Intergovernmental Risk Management Agency (IRMA) and Intergovernmental Personnel Benefit Cooperative (IPBC) seeks financial compensation from companies including Allergan, Johnson &...


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PA Expands Access to Medication Assisted Treatment for SUD

by Thomas Beaton

Commercial payers and the Pennsylvania Department of Insurance (PDI) have agreed to increase access to medication-assisted treatments (MAT) and realign prior authorization processes for beneficiaries struggling with substance use disorders...

Private Insurance Spending Has Outpaced Public Spending Since 2016

by Thomas Beaton

Private insurance spending has grown faster than Medicare and Medicaid spending since 2016, even though national enrollment has plateaued, says a new report from Altarum. The report suggests that higher per-enrollee spending, plus...

Managed Care Payers Struggle to Staff Long Term Support Services

by Thomas Beaton

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...

Payers Can Leverage Telehealth for Chronic Disease Management

by Thomas Beaton

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

by Thomas Beaton

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...

OIG Finds Profits to Blame for Denied Medicare Advantage Claims

by Thomas Beaton

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...

NYCHH Triples Denials Recovery from UnitedHealthcare to $40.1M

by Thomas Beaton

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

by Thomas Beaton

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

by Thomas Beaton

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...

NCQA, Health Plans to Measure Patient-Reported Outcomes

by Thomas Beaton

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

by Thomas Beaton

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...

Top Health Plans Excel in Preventive Care, Chronic Disease Management

by Thomas Beaton

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...

Medicare-Medicaid Dual Eligible Care Models Aim to Coordinate Care

by Thomas Beaton

Medicare and Medicaid dual-eligible care models provide extensive care coordination to ensure beneficiaries with multiple chronic conditions can access healthcare services, according to a new AHIP report.   Twelve million Americans...

Reference Pricing Models for Prescription Drugs May Contain Costs

by Thomas Beaton

Reference pricing models for prescription drugs may help to contain spending and reduce high costs for beneficiaries, says a new report from the Commonwealth Fund. Currently, most payers use tiered drug formularies to manage drug costs,...

Poor Healthcare Literacy Leads to $4.8B in Administrative Costs

by Thomas Beaton

Widespread rates of poor consumer literacy within the healthcare industry creates administrative burdens for payers and contributes to an additional $4.8 billion in health plan costs, according to a new Accenture report. Fifty-two percent...

Cigna Launches $250M Venture Fund for Analytics, Digital Health

by Thomas Beaton

Cigna will invest $250 million in the new Cigna Ventures fund, which will invest in healthcare startups specializing in analytics, digital health, retail, care management, and other business opportunities related to value-based...

FDA Recruits Payers to Submit Quality Feedback on Medical Devices

by Thomas Beaton

FDA has launched a new quality assurance program that leverages feedback from commercial payers about medical device coverage requirements in order to expedite approvals. The Private Payor Program (PPP) is a voluntary program for medical...

Da Vinci Project Connects Payers, Providers, FHIR for Value-Based Care

by Thomas Beaton

Payer and provider members of the Da Vinci Project are undertaking a series of pilot projects exploring how to best leverage FHIR for data exchange to enhance value-based care. “Da Vinci is a collective initiative of concerned,...

Handful of States Propose Lower ACA Premium Rates for 2019

by Thomas Beaton

Several states have announced lower ACA premium rates for 2019, bucking a national trend brought on by unstable markets and regulatory changes.   While early proposals from a number of states, including Virginia, Maryland, and...

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