Plans should be prepared for the difference between operational and financial success

Dawn Carter, Edifecs

In the first part of this series, we looked at a transformative year in healthcare and presented the ongoing shift from the Risk Adjustment Processing System to the Encounter Data Processing System.

Here we present submission deadlines and what success does, and doesn't mean, so plans are not surprised when a high acceptance rate results in unexpected file rejections or a lower than estimated risk transfer or reinsurance payment.

Engaging providers means aligning their goals with that of the consumer

Dianne Wagner of Florida Blue, and Carolyn Wukitch of McKesson

In our last column, we took a look at how U.S. health plans operate in a world of rising expectations based on: value-based reimbursement; consumerization; healthcare cost management; and regulatory compliance.

In this second part of the series, we'll give the best strategic plan of attack for each of these four trends.

Feature Video

The Obama Administration recruited Seattle Seahawks quarterback Russell Wilson and cornerback Richard Sherman to the game of selling the Affordable Care Act.

President Obama acknowledges the technical issues with HealthCare.gov, pledging his Administration will resolve them soon and asserting that the distressed web portal is not the only way to shop for affordable health insurance available through the ACA.


Three years after launching a 750-patient Medicare Advantage collaborative care pilot, Portland, Maine-based independent physician practice NovaHealth and insurer Aetna have shown concrete results in improving care quality and reducing costs. Technology and provider-payer cooperation played a large part in the program's success.

While CMS said it was "pleased to report that claims are processing normally," it's worth keeping in mind that the government agency has taken several temporary steps to smooth the transition to ICD-10 which may be masking problems that could manifest themselves down the road.

Many primary care practitioners will be a little poorer next year because of the expiration of a health law program that has been paying them a 10 percent bonus for caring for Medicare patients.

People with hepatitis C who sought prescriptions for highly effective but pricey new drugs were significantly more likely to get turned down if they had Medicaid coverage than if they were insured by Medicare or private commercial policies, a recent study found.

A new report by The Commonwealth Fund has found that a quarter of working-age adults struggle to pay for their healthcare in 2015 in the wake of rising deductibles and out-of-pocket costs.

As beneficiaries explore options during the current Medicare enrollment period, there are only 227 such plans from which they can choose next year, 20 percent fewer than this year, and the lowest number since the drug benefit was added to Medicare in 2006, according to the Centers for Medicare & Medicaid Services.

UnitedHealth Group may exit the insurance exchange market, as the deterioration in product performance has weakened its financial outlook, the company said in an earnings update released Thursday.

Many said they anticipate the federal government will act to forestall widespread departures, particularly because continued withdrawals could be politically explosive during an election year.

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