Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payers

AHA Makes Suggestions for In-State Insurance Market Stabilization

January 19, 2018 - In order to stabilize in-state insurance markets, stakeholders should consider strategies including reinsurance, Medicaid-sponsored health plans, and high-risk pools, according to the AHA. Several factors are contributing to unstable state insurance markets, including demographic characteristics, limited payer competition, a lack of Medicaid expansion, continued use of transitional health...

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Payers, Providers Pledge to Improve Prior Authorizations

by Thomas Beaton

AHIP, BCBSA, AHA, and other leading payer and provider organizations announced an industry pledge to improve the efficiency of prior authorizations while reducing administrative burden. Leaders of organizations participating in the pledge claim...

Payers Leverage Data, Wellness Benefits to Address Opioid Abuse

by Thomas Beaton

Providing substance use disorder (SUD) treatment options and making investments in beneficiary drug safety is a critical component of wellness programs, considering that the White House deemed opioid abuse a public health emergency in 2017. In...

Payers Support Integrated Care Services for NC Medicaid Patients

by Thomas Beaton

Payers and provider organizations that support integrated care systems can help lower healthcare costs by addressing the healthcare concerns of vulnerable patient populations, including Medicaid beneficiaries. Several commercial payers have recently...

Humana Becomes Latest Payer to End AHIP Membership

by Thomas Beaton

Humana is the latest commercial payer to end its membership in AHIP, the nation’s largest health insurance trade organization. “Humana has not actively participated in AHIP since early 2017,” a Humana spokesperson told

Outcomes-Based Contracts Offer Payers New Pharmaceutical Options

by Thomas Beaton

Payers may be more willing to provide their beneficiaries with genetic drug therapies that costs hundreds of thousands of dollars if they enter into outcomes-based pharmaceutical contracts that lessen financial risks. An outcomes-based pharmaceutical...

Top 10 Highest Performing Commercial Health Plans

by Thomas Beaton

The top performing commercial health plans in the US for 2017-18 exceeded expectations for customer satisfaction, preventive care, and outcomes of their beneficiaries, according to the National Committee for Quality Assurance (NCQA). NCQA aggregated...

Considerations for Designing Consumer-Directed Health Plans

by Thomas Beaton

Employers and health plans are rapidly adopting consumer-directed health plans (CDHPs) as a way to lower benefit costs and encourage cost-effective care utilization among beneficiaries. CDHPs are becoming part of many US employers’ efforts...

Expanding Air Ambulance Service May Help Payers Control Costs

by Thomas Beaton

Expanding air ambulance benefits may help payers lower beneficiary premiums and help beneficiaries avoid several thousand dollars in out-of-pocket healthcare spending. An air ambulance costs between $12,000 to $25,000 per flight to account for...

How Payers Can Build a Successful Bundled Payment Strategy

by Thomas Beaton

Bundled payment models are a popular reimbursement option for payers because they present an opportunity to improve healthcare quality, lower costs, and participate in value-based agreements with limited financial risk.   However, if payers...

Proposed Rule Details Association Health Plan Expansion Guidelines

by Thomas Beaton

The Department of Labor (DoL) released a proposed rule that allows small businesses and employee groups to purchase association health plans (AHPs) in lieu of employer-sponsored or individual health insurance. The rule follows an executive order...

Wellness, Preventive Care to Drive Employer Health Plans in 2018

by Thomas Beaton

Employer-sponsored health plans are expected to widely embrace value-based purchasing agreements and patient engagement technologies that improve employee wellness programs and preventive care, according to the National Business Group on Health...

Healthcare Insurance Market Profits May Hold Steady in 2018

by Thomas Beaton

Certain segments of the healthcare insurance market, including employer-sponsored insurance and Medicare Advantage (MA), will help to stabilize payer profitability in 2018, predicts a report by A.M. Best. The gains from these sectors are expected...

All-Payer Claims Databases Offer Insights into Healthcare Spending

by Thomas Beaton

All-payer claims databases (APCDs) allow payers, providers, and regulators to analyze claims from millions of beneficiaries to learn where spending is directed and whether or not spending on certain healthcare services is avoidable. State-level...

How Payers Can Streamline Prior Authorization for Prescriptions

by Thomas Beaton

Prior authorization may allow payers to limit unnecessary spending on high-cost prescription drugs, but leading provider experts suggest that payers could do more to boost the efficiency of prior authorization procedures for clinically valid...

How Process, Outcome Measures Contribute to Population Health

by Thomas Beaton

Payers rely on process and outcome quality measures to communicate healthcare performance to new and current beneficiaries. Quality measurements such as HEDIS, CMS Star Ratings, and standardized core quality measures (CQMs) are some of the tools...

Payer, Provider Collaboration Required for Accountable Care Success

by Thomas Beaton

The accountable care organization (ACO) movement has gained traction over the last year as payers and providers begin to share the same viewpoints on the benefits of value-based care. Provider attitudes about ACOs and related value-based care...

Member Engagement, Medicare Advantage Growth Top 2018 Payer Trends

by Thomas Beaton

2018 is a year in which payers are likely to implement strategies aimed at improving growth in Medicare Advantage markets, increasing the use of the social determinants of health  to improve outcomes, and expanding member engagement with...

Medicare Advantage Cost Benchmarks Create Plan Inefficiencies

by Thomas Beaton

New research from the Commonwealth Fund found that the Medicare Advantage (MA) benchmark bidding system, which was intended to reduce plan inefficiencies, has allowed health plans to benefit financially while remaining cost inefficient. Since...

2018 ACA Open Enrollment Totaled 8.82M Beneficiaries in Last Week

by Thomas Beaton

Approximately 8.82 million beneficiaries enrolled in a health plan during the seven week 2018 ACA open enrollment period, which experienced surges in health plan purchasing activity during the final two weeks. The opening week of 2018 open...


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