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Claims Management News

ACA Risk Adjustment, Reinsurance Improved Payer Financials

April 7, 2017 - 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 ACA implementation, 30 percent of insurers with the highest claims cost lost between $90-$397 per enrollee per month. After the first two years under...


Articles

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...

Why Payers Should Reduce Cost Sharing for High-Value Care

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Today, more healthcare payers are positioning greater cost-sharing onto the consumers to keep from raising premium rates, according to commentary published in JAMA Internal Medicine. The 2016 National Health Insurance Survey discovered that 40...

How Payers, Providers Could Streamline Medical Claims Management

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Successful medical claims management and processing is not always easy to garner for health insurance companies due to a lack of training among insurance agents, missing or inaccurate documentation, and the general time-consuming aspect...

4 Key Ways Payers Could Reach HEDIS Score Thresholds

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Health payers looking to increase consumer satisfaction and member retention may need to reach care quality metrics and HEDIS measures. The National Committee for Quality Assurance (NCQA) is responsible for many aspects of HEDIS measures and...

How Healthcare Payers Could Reduce Wasteful Spending

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For many years, the health insurance industry has been working to address wasteful spending among hospitals and medical practices. Some of the areas of wasteful spending relate to duplicative medical testing, unnecessary diagnostics, and excessive...

4 Ways Payers Could Improve Healthcare Price Transparency

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Healthcare price transparency remains a key issue for health payers across the country. In order to strengthen member retention efforts especially during open enrollment periods, payers will need to boost price transparency to improve consumer...

How Payers Could Improve Population Health Management with Tech

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When payers transition their reimbursement structures toward a value-based care payment model, healthcare quality improvement needs to be addressed. In order to boost quality, payers could target population health management and data analytics...

Key Ways Payers Could Improve Medical Claims Management

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Medical claims management is a key aspect of the payer-provider relationship. However, medical claims management tends to include multiple challenges for both payers and providers. Some of the problems stem from a lack of training in medical...

Patient Engagement Helps Payers on Affordable Care Act Exchanges

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Many health insurance companies selling health plans through the Affordable Care Act exchanges have been seeing higher and higher rates of financial losses. Some payers such as Aetna, Humana, and UnitedHealth Group have even pulled back from...

Health Payer Solutions for Improving HEDIS Quality Scores

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Payers and providers transitioning to value-based care reimbursement need to commit to meeting and improving their HEDIS quality scores. However, the documentation involved in reporting HEDIS quality scores tends to become complex. Johns...

How Health Payers Could Help Reduce High Out-of-Pocket Costs

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A major problem still impacting consumers within the health insurance market is the potential for seeing high out-of-pocket costs. Many individuals are still underinsured despite the significant decrease in the uninsured rate around the country...

Rise in High-Deductible Health Plans Requires Cost Transparency

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High-deductible health plans are becoming more and more common across the health insurance industry. With the many changes that the Affordable Care Act (ACA) has brought, payers are attempting to control costs by offering more high-deductible...

Healthcare Payers Face Challenges with Medical Loss Ratio

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Under the Patient Protection and Affordable Care Act’s medical loss ratio, health payers are required to spend a minimum of 80 percent of their premium revenue on paying claims and boosting quality while the rest (20 percent) can be spent...

3 Key Steps for Health Payers to Meet HEDIS Quality Measures

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Health insurance companies are slowly moving toward adopting alternative payment models based on pay-for-performance metrics. This means more payers and providers are focused on meeting HEDIS quality measures. The scores payers receive on HEDIS...

How Payers Could Use Price Transparency to Boost Satisfaction

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In order to reduce ever rising healthcare costs, health insurance companies will need to improve price transparency among their health plans as well as within their provider networks. The Robert Wood Johnson Foundation released a report showing...

How Provider Portals Streamline Medical Claims Management

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Healthcare payers have often struggled to process claims and provide effective customer service in a more streamlined manner due to technological inefficiencies. Insurers have faced challenges with engaging both their consumer base as well as...

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