Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Healthcare Payers

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...

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...

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...

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,...

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...

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...

Commercial, Public Payer Healthcare Fraud Cases Total $21.6M

by Thomas Beaton

The latest string of commercial and public payer healthcare fraud cases totaled $21.6 million from providers launching various schemes such as patient kickback agreements and false claims submissions. Public payer programs are frequently...

Assessing Providers for Participation in Value-Based Care Contracts

by Thomas Beaton

Creating strong networks of high-quality healthcare providers can be a major challenge for any payer looking to expand its value-based care contract portfolio. Providers aren’t the only ones accepting risk when entering into...

Cigna Files with SEC to Begin $67B Express Scripts Acquisition

by Thomas Beaton

Cigna has submitted a filing to the Securities and Exchange Commission (SEC) to complete a $67 billion acquisition of the pharmacy benefit manager (PBM) Express Scripts. The payer filed the merger agreement under a temporary parent...

Adding Telehealth, Remote Care Benefits into Health Plan Options

by Thomas Beaton

Payers that include telehealth and remote care benefits in their health plan options could position themselves as leaders in health plan value, convenience, and innovation. Health plans are challenged to improve customer service and...

More Competition May Benefit Medicare Advantage Bidding Process

by Thomas Beaton

The Medicare Advantage (MA) bidding process requires more competition to increase the availability of high quality MA plans for beneficiaries and reduce federal spending, according to a new Brookings Institute report. Brookings analysts...

Commercial Health Plan Customer Satisfaction Remains Steady

by Thomas Beaton

Commercial health plan customer satisfaction rates remained stable from 2017 to 2018, but payers still have a number of opportunities to improve their customer service and beneficiary education, according to a new JD Power consumer...

CMS Increases Payments for Durable Medical Equipment

by Thomas Beaton

CMS has issued an interim final rule that raises Medicare payments for durable medical equipment (DME) to ensure Medicare beneficiaries have access to critical medical devices. The rule will raise DME payments to Medicare providers from...

Improving Health Plan Customer Service Through Technology

by Thomas Beaton

High quality health plan customer service is critical for payers who want to create meaningful, positive beneficiary interactions. Customer service plays several important roles for health plans.  In addition to the stand-alone goal...

How Payers Can Address Food Insecurity among Plan Beneficiaries

by Thomas Beaton

Payers are constantly challenged to provide their health plan beneficiaries the best possible healthcare experiences, but may have trouble doing that if members experience food insecurity. Food security is just one lifestyle need that...

Harvard Pilgrim, Partners HealthCare Discuss Possible Merger

by Thomas Beaton

Harvard Pilgrim and Partners HealthCare are engaging in discussion of a possible merger.  A deal would combine Massachusetts’s largest payer organization with the state’s largest provider group and may create a dominant...

Supplemental Insurance is a Value-Add Opportunity for Employers

by Thomas Beaton

Employers may have a prime opportunity to add value to their health plan options by offering supplemental insurance, according to a recent AHIP survey. The survey found that 95 percent of employees are satisfied with supplemental plan...

How Payers Can Effectively Scale Value-Based Care Networks

by Thomas Beaton

Value-based care networks are a promising opportunity for payers that want to manage costs and improve outcomes of beneficiaries.  But effectively scaling collaborative, risk-based reimbursement networks for millions of beneficiaries...

Uninsured Rate among Working Adults Rises to 15.5% in 2018

by Thomas Beaton

The uninsured rate of working adults ages 19 to 64 rose by more than 3 percent between 2016 and 2018, according to the Commonwealth Fund’s ACA Tracking Survey. In 2016, 12.2 percent of working adults lacked health insurance....

CMS Proposes Value-Based Payment for Skilled Nursing Facilities

by Thomas Beaton

CMS has proposed to implement value-based payment reforms for skilled nursing facilities (SNFs) and other Medicare inpatient facilities in order to reduce fraud and create higher quality healthcare experiences for beneficiaries. The...

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