Ask the Experts

Ask the Experts

• PHE unwinding work may aid Medicaid, CHIP final rule compliance

  Some states have already cut in-person interviews and limited renewals to once a year, aligning with Medicaid and CHIP final rule policies.  Continue Reading

• With Proper Use, Artificial Intelligence Improves Health Plan Operations

  Health plans must fully understand artificial intelligence tools before using them to assist with coverage determinations or administrative tasks.  Continue Reading

• What Is Behind Rampant Medicare Advantage Contract Terminations?

  Health systems do not invest in the infrastructure needed to support Medicare Advantage, while health plans offer low reimbursement, leading to contract terminations.  Continue Reading

• How One Payer Tackled the No Surprises Act Provider Directory Rule

  Since the No Surprises Act went into effect, payers and providers have struggled to keep up with certain provisions and many wonder if automation can fill the gaps.  Continue Reading

• 2024 Payer Strategies: Population-Based Plans, MA Differentiation

  In 2024, payer strategies will include improving health equity partnerships, differentiating their Medicare Advantage plans, and offering care navigation.  Continue Reading

• How Healthcare Leaders Can Weigh Pros, Cons of Payer Megamergers

  Payer megamergers can have mixed results and the overall impact largely hinges on the companies' commitment to value-based care principles.  Continue Reading

• Blue Cross Blue Shield of MA Eliminates More Prior Authorizations

  The payer focused on prior authorizations that may slow down the transition from hospital care to home care.  Continue Reading

• 3 Steps One Medicaid MCO Took to Boost Its Patient Experience Score

  Patient experience is a key measure in the NCQA health plan rating system, but two components—ease and speed of access to care—can be hard to achieve.  Continue Reading

• What Cigna’s FCA Settlement Means for Other Medicare Advantage Plans

  Per its settlement, Cigna must conduct annual risk assessments, but all Medicare Advantage plans should be proactively monitoring their compliance actions.  Continue Reading

• The Medicare Advantage Marketing Problem and Where It’s Headed

  With new Medicare Advantage marketing regulations in place for 2024, payers must work with their marketing teams and establish proactive oversight programs to ensure compliance.  Continue Reading

• Medicare Advantage RADV Rule May Prompt More Legal Action from Payers

  Humana’s lawsuit has created a roadmap for other payers who may want to take legal action against CMS and the Medicare Advantage RADV final rule.  Continue Reading

• Top Reasons Behind Retail, Medicare Advantage Plan Partnerships

  Co-branded Medicare Advantage plans may address prescription drug spending and access to care among seniors but require significant alignment between payers and retailers.  Continue Reading

• How Can Medicare Advantage Organizations Prepare for RADV Audits?

  Ahead of RADV audits, Medicare Advantage plans must internally review charts, invest in compliance programs, and monitor coding vendors.  Continue Reading

• Payer Turns to PBM Coupon Program to Lower Prescription Drug Spending

  In the first quarter of 2023, the program resulted in $4.5 million in reduced prescription drug spending for participating employer groups.  Continue Reading

• Key Strategies for Transitioning a Health Plan into Cloud Computing

  Cloud computing technology adoption is on the rise worldwide, but how can health plans shift their complex processes into this new platform?  Continue Reading

• How One MA Plan Prioritized SDOH to Improve Diabetes Care Access

  Zing Health facilitated access to diabetes care by providing continuous glucose monitors at pharmacies for no cost.  Continue Reading

• First Impressions Count: How Onboarding Affects Member Engagement

  From the first point of contact to tracking the results on welcome package touchpoints, onboarding strategies are key to forming a strong payer-member relationship.  Continue Reading

• How Long-Term Health Plan Enrollment Supports Value-Based Care

  Long-term health plan enrollment can allow for better investments that drive lasting positive health outcomes.  Continue Reading

• Slow but Steady: Experts Report on 2023 Mergers and Acquisitions Trends

  Policy changes, portfolio renewals, and regulatory reviews will impact mergers and acquisitions in 2023.  Continue Reading

• Improve Coverage, Health Equity By Diversifying Broker Recruitment

  Access to care can vary based on access to health insurance brokers, so when broker pools lack diversity health equity suffers.  Continue Reading

• How One Payer Redesigned Wellness Program Rewards Around Choice, Tech

  UnitedHealthcare redesigned its rewards for wellness program participation to incorporate a wider range of options for members and more advanced technologies.  Continue Reading

• The Future of Medicare Advantage Risk Adjustment Data Validation

  Blue Cross Blue Shield Association, Humana, Avalere, and MedPAC address the impacts of the finalized Medicare Advantage Risk Adjustment Data Validation rule.  Continue Reading

• How States Can Prepare for 2023 Medicaid Redeterminations

  States face many challenges as the start date for Medicaid redeterminations approaches, but they can take steps before, during, and after redeterminations to mitigate major missteps.  Continue Reading

• Going Beyond Benefits: How Employers Can Assess, Create Wellness Culture

  Surveys have demonstrated that employers and employees do not share the same opinion on employer mental health initiatives, so how can employers improve wellness culture?  Continue Reading

• Top Predictions for Health Insurers, Employers in the New Year

  Experts’ top predictions indicate that insurers and employers will face high costs and other challenges but will also find opportunities in places like specialty pharmacy.  Continue Reading

• How Payer, Provider Alignment Enables Simplified Medical Billing Format

  After years of working toward this goal, the payer and provider partners introduced a simplified medical billing format, in part made possible due to their joint venture model.  Continue Reading

• Improving Accessibility for Spanish-Speaking Seniors in Medicare Advantage

  Spanish-speaking seniors face a variety of challenges in navigating Medicare, but payers can take steps to demystify the system by providing authentic Spanish-speaking services.  Continue Reading

• How Employers Can Achieve a Fair Price in Hospital Negotiations

  With healthcare costs skyrocketing, it is time for employers to take the reins on negotiating hospital prices to achieve a fair price.  Continue Reading

• How AZ Medicaid Expanded Its Role in Social Determinants of Health Coverage

  Arizona's Medicaid program took on an innovative role in addressing social determinants of health, particularly in housing.  Continue Reading

• Value-Based Care Implementation Requires Investments, Collaboration

  Rocky Mountain Health Plans in Colorado implemented its value-based care model over a decade ago, but continuous success hinges on collaboration between stakeholders and investments in key resources.  Continue Reading

• How One Payer Expanded the Boundaries of Maternal Healthcare Benefits

  BCBSM expanded its maternal healthcare benefits to encompass more of the childbirth and child-rearing journey.  Continue Reading

• How MN Medicaid Used Community Engagement to Address Health Disparities

  Minnesota’s Medicaid program addressed health disparities and improved maternal health through community engagement initiatives that sought feedback from Black and American Indian beneficiaries.  Continue Reading

• How the Inflation Reduction Act Will Impact Employers, Health Plans

  The Inflation Reduction Act has generated concerns that Medicare drug price negotiations could lead to additional costs for employers and employer-sponsored health plan members.  Continue Reading

• Top Factors Influencing Employer Sponsored Health Plan Premiums in 2023

  Employer-sponsored health plan premiums for 2023 will be subject to inflation and utilization trend changes, along with some lingering effects from the coronavirus pandemic.  Continue Reading

• Top Payer Strategies Around Payment Models for Advanced Therapies

  Payment models for advanced therapies have to incorporate well-defined outcomes measures, ensure that the drug’s price reflects its value, and comply with state and federal regulations.  Continue Reading

• How Payers Can Move Providers Along Value-Based Care Continuum

  As providers move along the value-based care continuum, payers can offer financial and technical support, help them pursue primary care transformation, and present further research.  Continue Reading

• What Are Employer Sponsored Wellness Programs?

  Employer sponsored wellness programs can address any of five or more domains of wellness, including social, financial, and environmental wellness.  Continue Reading

• Top Challenges, Benefits of At-Home Coronavirus Testing Coverage

  Changes in at-home coronavirus testing coverage have created opportunities and challenges for payers as the pandemic reshapes preventive care services.  Continue Reading

• How to Introduce Medicare Advantage Caregiver Benefits in SNPs

  Medicare Advantage caregiver benefits should seek to educate members’ caregivers and listen to caregivers’ needs through multimodality.  Continue Reading

• Applying Whole Person Care to Digital Care for Underserved Members

  Too often Medicaid beneficiaries receive transactional care, but payers can leverage digital solutions such as e-consulting services to advance whole person care.  Continue Reading

• How to Hone Wellness Programs Using Social Determinants Data

  Payers and employers can collaborate to create more effective wellness programs by leveraging social determinants of health data from community sources.  Continue Reading

• Top Employer Strategies for Implementing Episodes of Care Models

  Employers looking to enter into episodes of care models should consider seizing control of their own data and engaging in direct contracting with providers.  Continue Reading

• How Payers Help Tackle Substance Use Disorders, Other Conditions

  Payers have several opportunities to improve their coverage options for members who have substance use disorders with co-occurring conditions.  Continue Reading

• The State of Payer, CBO Social Determinants of Health Contracting

  Health plans and community-based organizations face numerous challenges in the new world of social determinants of health contracting.  Continue Reading

• How Payers Can Launch a Virtual-First Health Plan

  Virtual-first health plans appear to be the natural next step in the evolution of virtual care, remote care, and telehealth technology. How can payers launch a successful plan?  Continue Reading

• How Payers Can Improve Cancer Patient Navigation, Experience

  Cancer patient navigation through the healthcare system is notoriously challenging, but payers can help states improve that reputation.  Continue Reading

• Going Beyond Compliance: How Payers Can Embrace Healthcare Interoperability

  CMS is requiring healthcare interoperability from payers but embracing more data-sharing with the consumer in mind will be key to future success for health plans.  Continue Reading

• Two Critical Impacts of 2021 Special Enrollment Period Gains

  Due to the unique circumstances of the coronavirus pandemic, 2021 special enrollment period gains could have a major influence on customer service needs and risk adjustment.  Continue Reading

• Strategies for the Physical-Behavioral Healthcare Integration Puzzle

  Leveraging value-based care, correctly assessing the technology’s capabilities, and empowering primary care are at the heart of physical and behavioral healthcare integration.  Continue Reading

• How Payers Can Improve Attachment Processes in Claims Management

  Exchanging attachments is one part of the claims management process that payers can improve upon to save time and money for both payers and their provider partners.  Continue Reading

• Key Considerations For Implementing Diabetes Management Programs

  For payers looking to create or bolster diabetes management programs, it is critical to address mental health, include wellness programming, and persist in member engagement.  Continue Reading

• Creating Strategies to Expand Transgender Healthcare Coverage

  Data collection and stakeholder communication are key, but ultimately transgender healthcare coverage is a matter of listening and acting.  Continue Reading

• How Payer Forecasting Is Shifting Towards Real-Time Data Analytics

  A real-time data analytics approach demands that payers pursue full interoperability and requires a different mindset than the traditional approach has required.  Continue Reading

• In 2020 Consumerism Will Steer Payer Decisions in Deals, Spending

  While consumerism in healthcare is nothing new, it will play an even greater role in how payers make deals, use technology, hire, pursue equity, and spend.  Continue Reading

• Legal, Payer Experts Unpack SCOTUS Affordable Care Act Hearing

  While the final outcome is unpredictable, payer and legal experts shared their expectations regarding the Affordable Care Act case and reviewed the progress of the law itself.  Continue Reading

• Key Considerations for Permanently Integrating Telehealth Coverage

  As telehealth transitions from a nice-to-have benefit to an essential form of care delivery, payers will have to make some adjustments in order to permanently integrate telehealth coverage expansions.  Continue Reading

• 4 Strategies to Advance Value-Based Care During and After a Crisis

  Four experts in value-based care share how a major disruption to the healthcare industry, like the COVID-19 pandemic, could be used to advance payer value-based care progress.  Continue Reading

• Navigating Medigap Plans: How Payers Can Lead the Way

  Payers can play a key role in helping consumers understand their Medigap benefits and policy options through greater benefit and price transparency.  Continue Reading

• Collaboration, Patient Education Key to Increasing Medicaid Coverage

  Many individuals experiencing coronavirus-related job loss do not know they are eligible for Medicaid. But provider collaboration and patient education can ensure these patients receive proper coverage.  Continue Reading

• Beyond COVID-19: Telehealth, Partnerships, Member Engagement

  Payers have been on the frontline of COVID-19 response efforts, but now plan leaders are grappling with how to handle telehealth, partnership, and member engagement in a post-pandemic world.  Continue Reading

• The Building Blocks of an Effective Coronavirus Response Strategy

  The coronavirus pandemic has forced payers to leverage strategies for engaging members, providers, employees, and the community to fight COVID-19.  Continue Reading

• How Peer Recovery Increases Medication Adherence, Lowers Spending

  Through a partnership with Anchor Peer Recovery, BCBSRI is seeing greater treatment and medication adherence in substance abuse care.  Continue Reading

• Virtual Behavioral Health Visits Improve Care Access

  Cigna’s partnership with MDLIVE gives members the ability to schedule and attend virtual behavioral health appointments, improving adherence and access to care.  Continue Reading

• How Medicare Advantage Is Leading Payers to Adopt Value-Based Care

  The transition to value-based care has stalled, but the unique structure of Medicare Advantage can help payers advance to lower costs and better outcomes.  Continue Reading

• Accessible Data, In-Person Dialogue Key to Value-Based Partnerships

  Payers and providers discussed accessibility and the benefits of in-person dialogue for value-based partnerships at Xtelligent Healthcare Media’s Fourth Value-Based Care Summit.  Continue Reading

• Employing Social Workers to Address Social Determinants of Health

  Florida Blue is using social workers to help community members in their retail centers address social determinants of health.  Continue Reading

• Optima Health’s Medicaid Addresses Food Security, Social Determinants

  Optima Health collaborates with Solutran’s Healthy Savings program to lower financial barriers to healthy food options, increase food security and address other social determinants of health.  Continue Reading

• 5 Strategies for 5 Stars: Cigna's Approach to CMS Star Ratings

  An organization-wide commitment to focus on patient experience, preventive health, care coordination, and customer service is leading to star rating success at Cigna.  Continue Reading

• Using Medically-Tailored Meals to Boost Chronic Disease Care

  At Health Partners Plans, a medically-tailored meal delivery program is improving outcomes and reducing costs for members with chronic disease.  Continue Reading

• What's the Role of Medicare Advantage for Payers and Consumers?

  What is Medicare Advantage, and how can payers successfully design these plans to maximize value for beneficiaries?  Continue Reading

• How Payer Philanthropy Can Address Social Determinants of Health

  Payers looking to reduce their downstream spending are pouring millions into addressing the social determinants of health in the community setting.  Continue Reading

• Key Steps for Payer Success in Accountable Care Organizations

  When accountable care organizations strive to improve patient engagement, population health management, and data sharing, greater success can be achieved.  Continue Reading

• Private Payers Follow CMS Lead, Adopt Value-Based Care Payment

  Value-based care payment contracts are becoming a mainstay of the healthcare industry from federal agencies to providers and commercial payers.  Continue Reading

• How Medicare, Medicaid, and CHIP Guide the Health Payer Industry

  Public coverage programs like Medicare, Medicaid, and CHIP are leading the way in value-based care payment models.  Continue Reading

• How Health Insurance Mergers Could Change the Payer Industry

  Potential health insurance mergers have come under such close scrutiny as a result of concerns over how they will change the payer landscape if completed.  Continue Reading

• How Payers Could Succeed in ACA Health Insurance Exchanges

  Payers should take advantage of the competition available through the ACA health insurance exchanges in order to succeed.  Continue Reading

• How Payers Should Prepare for Value-Based Reimbursement

  Payers and providers taking on value-based reimbursement arrangements must work towards reducing rates of hospital readmissions, hospital-acquired infections, and length of stay.  Continue Reading

• How Quality Metrics Affect Value-Based Care Reimbursement

  When negotiating contracts based on a value-based care reimbursement model, healthcare providers will need to bring more focus toward population health management and meet quality performance benchmarks.  Continue Reading

• How to Overcome the Challenges of Bundled Payment Models

  Physicians may find bundled payments a challenging form of reimbursement since there may be costs associated with a patient’s treatment that are out of their control.  Continue Reading

• How the Affordable Care Act Changed the Face of Health Insurance

  Why have health insurance rates gone up after the Affordable Care Act was implemented?  Continue Reading

• What Are the Benefits of Accountable Care Organizations?

  Value-based care payment stimulates more preventive care and a reduction of hospital stays as well as emergency room visits.  Continue Reading

• Time, Commitment Required for ACO, Value-Based Care Success

  Accountable care partnerships will need to have greater patience when it comes to earning shared savings.  Continue Reading