Medicare

Prospective Payment Integrity Moving from Pay and Chase to Predictive

This Spotlight examines payer payment integrity platforms and how payers can aggressively apply analytics and coordinate workflows to move "left" from reactive postpay to proactive, predictive prepay.

Source Editing

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Source Medicare Reimbursement

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Source Claims Modeling

GuidingCare Utilization Management

HealthRules Payer + Source Integration

GuidingCare Appeals & Grievances

What Sets Us Apart: Resiliency to Change

McLaren Health Plan Case Study

Prospective Payment Integrity Brochure

Large, National Health Insurer Case Study

Independent Health Case Study

CMS is Requesting Feedback on Establishing the First, National Directory of Health Care Providers & Services

Have you ever tried to find an in-network doctor on your health plan member portal, found one, and called them – only to find out that they’re not actually in network? Or worse, gone to a doctor...

The Future of Clinical Interoperability

Interoperability Challenges and Recommendations Introduction The U.S. Department of Health and Human Services (HHS) aims to have an interoperable health IT ecosystem by 2024. This ecosystem would...

Providers Struggle with Realities of Transparency

Providers Grapple with Regulatory Realities Providers appear to be grappling with the regulatory realities of value-based care, especially when it comes to data transparency. Although they claim...

“Stacking” Editing Solutions vs Prospective Payment Integrity

Improper claims payment and fraud contribute more than $200 billion to the annual cost of U.S. healthcare.1 Summary In order to generate cost savings, most U.S. healthcare payers: Focus on...

Why Automation Technology Will Disrupt Claims Processing

Summary Automated claims technologies are uniquely positioned to increase accuracy of claims because: Most claims paid by health insurers are based on predetermined rates Medicare and Medicaid...

Why Using Modern Technology is Critical to Serving the D-SNP Population

As the dual eligible population grows, Dual Eligible Special Needs Plans (D-SNPs) are also experiencing tremendous growth across the country. CMS reports that as of February 2022, D-SNPs are...

State of the D-SNP Market

Within Medicare Advantage (MA), there are Special Needs Plans (SNP) with specialty cohorts that provide coverage for members who qualify for both Medicare and Medicaid. The membership for these...

CMS Opens Portal for IDR Under No Surprises Act

In the ongoing struggle to achieve clarity around how Surprise Billing regulations will work, the Centers for Medicare and Medicaid (CMS) opened a Federal IDR Portal in late April to guide...