Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payers

PwC: Digital Experiences, High Costs Will Challenge Payers in 2019

December 12, 2018 - Healthcare payers that hope to succeed in 2019’s competitive business environment will need to meet the strong demand for more consumer-centered digital experiences that help members control their spending and understand how to improve their own health, according to PwC. The nation’s healthcare spending will continue its “unsustainably high” upward trajectory...


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AHIP, Payer Groups Agree to Focus on Nixing Surprise Billing

by Jennifer Bresnick

Nine of the nation’s most influential payer organizations, including AHIP and the Blue Cross Blue Shield Association (BCBSA), have released a new set of guiding principles aimed at eliminating surprise billing. Unexpected medical...

Aetna Joins Healthcare Blockchain Alliance, Pilot Project

by Kyle Murphy, PhD

Not long after closing its deal to be acquired by CVS Health, health payer Aetna has signed on to pilot the use of blockchain technology as part of the Synaptic Health Alliance. In a statement with new fellow participants Ascension, the...

Robocalls Targeted Consumers During Health Plan Enrollment Period

by Chuck Green

Health insurance open enrollment’s kicked off, accompanied by a spike in automated calls with offers of Affordable Care Act or other health plans, much to the chagrin of consumers. “It’s at epidemic levels at this time...

US District Court Denies Appeal to Resolve Risk Corridor Payments

by Thomas Beaton

Federal judges for the US Federal District Court of Appeals denied a request to reopen a case that could provide over $12 billion in risk corridor payments to payers. Moda Health Plan, BlueCross BlueShield of North Carolina, and Land of...

Employer-Sponsored Medicare Advantage Enrollment Up 12% for 2019

by Thomas Beaton

Employer-sponsored Medicare Advantage (MA) enrollment for plan year 2019 increased by 12 percent, representing a bump of more than 443,000 individual members, according to a new analysis by Mark Farrah Associates. Individual Medicare...

Commercial, Managed Care Insurance Sectors Profits Boom in Q3

by Thomas Beaton

Commercial and managed care payers experienced significant third quarter profits, reductions in healthcare spending, and enrollment growth, according to the latest financial statements from insurance companies. Medicare Advantage (MA),...

Cigna: Integrated Pharmacy, Medical Benefits Improve Overall Health

by Thomas Beaton

Integrating pharmacy benefits with medical benefits can help to improve overall health and reduce employer costs, according to a new study released by Cigna. Individuals with connected medical, behavioral and pharmacy health benefits...

Proposed Rule Alters HRAs to Allow Direct Reimbursement to Employees

by Thomas Beaton

The Departments of Labor, Treasury, and HHS have proposed a new rule that would allow employers to directly reimburse employees’ care costs through health reimbursement arrangements (HRAs) as an alternative to traditional insurance...

Medicare Advantage Plans Proliferate in 2019, Raising Competition

by Thomas Beaton

Medicare Advantage (MA) payer competition is increasing significantly for plan year 2019 as more than 400 new options hit an already-crowded market, says a new report from the Kaiser Family Foundation (KFF).   More than 2700...

IL Payers File Pharma Lawsuit Over Opioid Prescription Costs, Safety

by Thomas Beaton

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...

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...

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