Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management News

All-Payer Claims Databases Offer Insights into Healthcare Spending

January 2, 2018 - 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 all-payer claims databases can help stakeholders to manage population health and identify opportunities to reduce wasteful or preventable healthcare...


Articles

How Payers Can Streamline Prior Authorization for Prescriptions

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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...

Medical Device Data, UDIs on Claims Impact Costs, Patient Safety

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Adding medical device data and unique device identifiers (UDIs) to insurance claims could have a significant positive impact on healthcare spending and patient safety, according to reports from Pew Charitable Trusts, Brigham and Women’s...

Claims Analytics Help Medicare Identify, Prevent Provider Fraud

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Close to a quarter of new Medicare fraud investigations started with the use of a claims analytics platform that has helped to save approximately $6.7 million in incorrect billings, a new GAO report found.   After reviewing fraud prevention...

Pre-Authorizations, Rx Limits Cut Opioid Abuse by 30% Nationwide

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Anthem BlueCross BlueShield (BCBS) organizations across the country collectively pledged to lower opioid abuse by 30 percent, and the company as a whole reached that goal two years ahead of schedule according to a press release. Declared a national...

Small Employer Health Plan Quality on Par with Larger Groups

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Small employer health plans can deliver similar levels of quality with many of the same cost controls as larger employers, according to new research from United Benefits Advisors (UBA). A “less is more” approach can provide significant...

Stop-Loss Insurance a Growing Market Opportunity for Healthcare

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Even though payers may experience higher total revenues on commercial self-insurance, stop-loss and third-party protected insurance revenues have been growing at a higher rate with stronger market stability according to market research from AM...

Explaining Out-of-Pocket Costs May Ease Cancer Care Stress

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Patients who are not prepared for the magnitude of their out-of-pocket costs for cancer care are more likely to be distressed and less likely to pay their bills than other individuals, according to a research letter published in JAMA Oncology....

Can Healthcare Price Transparency Tools Cut Costs for Payers?

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As out-of-pocket costs for patients continue to rise alongside payer spending on services, many health insurance companies are turning to online price transparency tools to help beneficiaries decide how to purchase low cost, high quality care....

CMS Approves State Capitated Medicaid Program in Florida

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Florida received CMS approval to operate a state capitated Medicaid program and a low-income pool (LIP) to improve care for uninsured individuals, the federal agency announced. The state submitted a request to extend Florida’s Managed Medicaid...

Employer Cost Management Strategies Combat High Insurance Costs

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Employers expect healthcare spending to increase by 5.5 percent in 2018, up from a 4.6 percent increase in 2017, according to a Willis Towers Watson survey. The continued rise in costs has turned health cost management as a top employer concern,...

Payer Collaboration Can Address Social Determinants of Health

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Billions in overspending on medical costs are attributed to social determinants of health (SDOH), and SDOH can identify if beneficiaries covered by insurance plans are at risk for adverse health conditions outside their coverage. SDOH include...

How Can Health Savings Accounts Help, Hinder Patients and Payers?

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Health savings accounts (HSAs) have been widely discussed as lawmakers consider policy reforms, at the federal level, and have become a fixture in conversations about healthcare spending among payers and patients alike.   HSAs are consumer...

What to Look for in Health Insurance Enrollment Technology

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Health insurance enrollment technology is designed to offer payers convenience, cost savings, and administrative ease-of-mind when it comes managing beneficiaries enrolled in health plans. Many Americans face challenges when seeking new health...

Member Engagement for Payers Should Focus on Simplicity

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For payers, an effective member engagement strategy can lead to better member health, lower claims cost, and improved product loyalty.  To achieve these goals, payers should start by identifying pain points and implementing processes that...

ACA Risk Adjustment, Reinsurance Improved Payer Financials

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A new study published in Health Affairs found risk adjustment and reinsurance provisions of the Affordable Care Act improved financial outcomes for certain payers with higher risk enrollees.   Researchers from AHRQ and CMS found that before...

Does Tiered Cost-Sharing Promote Appropriate Medication Use?

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Health plans have traditionally used tiered formulary cost-sharing arrangements to reduce healthcare spending and incentivize appropriate medication use. But a recent Journal of Managed Care & Specialty Pharmacy study found that stakeholders...

Joint Replacement Bundled Payment Cut Costs, Maintained Volume

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A new Altarum Institute study confirmed previous research that bundled payment models for lower extremity joint replacements decreased care costs without sacrificing care quality or substantially increasing procedure volumes. In September 2016,...

How to Develop HEDIS Quality Measures for Pediatric Care

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The American Academy of Pediatrics (AAP) announced yesterday on its website that it will be partnering with the National Quality Forum (NQF) to connect quality metrics to the interests of children and pediatric care. The National Quality Forum...

How to Reduce Obesity Rates, Increase HEDIS Quality Scores

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When attempting to improve provider performance on HEDIS quality scores, healthcare payers may need to pick and choose the quality measures that could be realistically raised. For example, childhood obesity may be one of the most common health...

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