Regulatory change in healthcare rarely arrives all at once—but now, several major policy shifts are coming into effect on January 1, 2027. Health plans that start planning for these changes now...
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Key Takeaways As the January 1, 2027, Application Programming Interface (API) deadline approaches, many health plans are finding that testing is surfacing additional considerations they hadn’t...
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For Medicare Advantage plans, Star Ratings have always been a critical measure of quality and performance. But maintaining high ratings has become increasingly difficult. The numbers tell the...
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Key Takeaways January 1, 2027 is a major regulatory milestone. Multiple regulatory deadlines—including prior authorization API requirements, work requirement mandates, and the AMA obstetrics...
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How behavioral health, program integrity, end emerging CMS priorities are reshaping health plan operations
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Key Takeaways Post-hybrid review is a critical audit readiness phase: Success depends on strong documentation workflows, accurate validation, and timely support for auditor requests. Centralized...
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Key Takeaways For payers, inaction is not a neutral choice—legacy operating models carry compounding costs that erode financial performance, member satisfaction, and competitive positioning over...
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Achieving a 4.5-Star rating is a major accomplishment for any Medicare Advantage health plan. But moving from 4.5 to 5 Stars is a different challenge altogether. Only a small percentage of plans...
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With the recently released the 2027 Medicare Advantage Final Rule and Rate Announcement, The Centers for Medicare and Medicaid Services (CMS) confirmed it is finalizing payment rates at a...
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This year marked the 20th anniversary of the RISE National Conference, but the milestone felt less like a retrospective and more like a clear signal of where health plan risk adjustment is heading...
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Health plans often struggle to achieve performance goals due to limited resources, which can restrict their ability to execute critical quality improvement initiatives.
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For health plans, navigating the complexities of modern healthcare technology and operations is critical for sustainable success.
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In a dynamic healthcare environment, operational stability and continuous improvement are fundamental for health plans to ensure efficiency, effectiveness, and adaptability.
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When measuring success, gaps in care can play an impactful role in HEDIS measure score. Closing gaps in care has a direct impact on HEDIS scores.
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In 2024, Americans spent approximately $5.3 trillion on healthcare, about $15,474 per person, and healthcare expenditures accounted for 18.0% of the country’s GDP.
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At HealthEdge®, we strive to understand the key challenges health plans face so we can help anticipate and address new market opportunities. Recently, HealthEdge Chief Strategy Officer, Raj...
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The Centers for Medicare & Medicaid Services (CMS) has raised performance benchmarks for Medicare Advantage (MA) and Part D plans, raising the bar for achieving high Star Ratings. By excluding the...
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HealthEdge had the opportunity to sit down with Presbyterian Health Plan leadership to learn more about why their organization decided to make the switch to HealthRules Payer as it's CAPS partner.
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The Transparency in Coverage Guide (CMS-9915-F) is a pivotal regulation aimed at increasing transparency in healthcare pricing, enabling consumers to access price information before receiving services
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