current trends for health plan professionals

While prior authorization serves as vital checks and balances, ensuring clinical quality and preventing fraud, the administrative burden it imposes on providers and payers alike has led to an industry-wide reevaluation of...

AI solutions can offer valuable decision support to create efficiencies at scale, timeliness, and accuracy. However, AI solutions should not run autonomously, nor should the final result go unquestioned. It is essential that all stakeholders understand how AI solutions draw their conclusions...

As more and more provider organizations enter into risk sharing agreements, provider engagement programs are experiencing a surge in participation. Provider engagement programs improve the collaborative relationship between plans and providers but not all programs are suitable for every practice...

NLP is used in medical coding to enhance the speed, efficiency, and quality control for MAO risk adjustment. Tune in to discover the opportunities and limitations of NLP, why NLP is not replacing medical coders, and how organizations can customize NLP engines to meet....

In light of the 2023 Final Rule regarding RADV audits and potential extrapolation loss, plans are seeking ways to strengthen reimbursement accuracy...

There is a distinct advantage to enrollment technologies that are built specifically for CMS's enrollment and dis-enrollment regulations for Medicare Advantage and Part D.  One such specification includes...

We discuss the variables that influenced performance and why it's the second year in a row, the average Star Ratings have declined and some plans might be seeing less than ideal performance. More than a third of plans saw a Star Ratings decline this cycle. 

In this episode, we discuss the significant changes in the weight of Star measures in the 2023 Final Rule, the removal of the Reward Factor, the addition of the Health Equity Index, and how to play Stars like a math game...

Many plans attempt to close as many prospective gaps in a year as they can and whatever they cannot close in that year is sent to retrospective programs. This is a costly approach that tends to over-suspect and...

Best practices for Medicare and Medicare Advantage marketing and ads continue to evolve as greater numbers of seniors integrate digital activity, such as online news and Facebook, into their daily routines. While the goal of any campaign is to stop-the-scroll and convert...

CMS Interoperability and Patient Access Final Rule was developed to connect healthcare technology systems  so members can access their own data. All CMS-backed plans...

Technology is essential for today's care management operations, yet it's important to recognize that technology can either help or hinder the business. At its best, technology offers a reduction in...

Social determinants of health (SDoH) is an important variable to consider when interacting with Medicare Advantage populations and as the healthcare system increases its...

HEDIS hones in on 5 domains of care and measures whether the healthcare services rendered are actually improving conditions. The domains include effectiveness of care, access or availability of care, experience of ...

Technology debt is the cost of maintaining legacy software systems over time, often built in hard code. Updates and workarounds are expensive and the process for implementation is slow, but there's also the...

It’s hard to imagine a time when claims were submitted on paper. In 2003, Medicare required electronic submission of all claims via an electronic data interchange (EDI) for auto-adjudication. This means claims are...

The concept of marketing segmentation isn't new, but what may be new, is the idea of generational segments within the Medicare market. Until recently, messaging...

The weight of the CAHPS survey has steadily increased over the years from 8% in 2014 to 32% of the overall Star Rating in 2021. Scoring is complex and there’s no one size fits all strategy...

In the context of risk adjustment gaps, there are two overarching goals—to identify and accurately predict member conditions. To do this, health plans are reliant on...

Marketing and communications in the Medicare Advantage space have evolved significantly in the past five years. Leaving behind a one-size-fits-all outreach approach, today’s best practice is...

In this episode, we explore the origins of care management, reactive versus proactive models of care, ways to coordinate care with real time data, practical uses for...

2021 was the first year that CMS shifted away from clinical metrics and skewed the weight towards member experience. Health plans will need to address matters such as...

Join us for insider insights and perspectives for healthcare executives of government-sponsored health plans. We’re talking to the experts about...