Four ways to thrive in the midst of change

Sohil Goorha

Though the deadline for complying with significant reforms of the Affordable Care Act has come and gone, payer organizations across the country are still adapting to the newfound complexities of their evolving industry.

The hidden segment

Shiv Gupta

With the first healthcare exchange open enrollment period concluded, savvy health plan marketers are spending much of their time and resources sifting through enrollment data hoping to gaint insights. However, this is a new world for plan providers, and most current marketing plans and sales strategies were developed for commercial and Medicare sales.

Cloud, mobile promise to ease claims, authorization friction

Michael Arrigo

Health care providers have long expressed dissatisfaction with the time they spend coordinating care with health plans and getting paid. Indeed, one of the most inefficient and costly processes for both providers and payers is Prior Authorization.

The need for comprehensive Medicare Advantage compliance reviews

Vanessa Pawlak, Ernst & Young

For Medicare contract sponsors to remain viable, it's now necessary to perform a comprehensive Medicare program compliance review. Proposed rule changes may give CMS additional authority next year.

PBMs are a health plan's Achille's Heel

John Gorman, Gorman Health Group
John Gorman's picture

In this Golden Age of government programs, the health plan industry has never had more exposure to the generally poor performance of pharmacy benefit managers (PBMs). Performance metrics in Medicare, Medicaid and ObamaCare are directly tied to PBM execution, and the recent track record of these companies means they are the Achille’s Heel of insurers.

Group plans more susceptible than ever to security violations

Mary A. Chaput

Many healthcare executives fall prey to two common misconceptions about data breaches: that the only companies making headlines for lax data security are big retailers like Target and that the biggest culprits are teenage hackers or sophisticated teams working in China or Eastern Europe.

By 2020, most states will be on the federal exchange

John Gorman, Gorman Health Group
John Gorman's picture

As ObamaCare launched last fall you'll recall 16 states started their own exchanges. 

Is the ACA really a job-killer?

David Williams, Health Business Blog
David Williams's picture

The Affordable Care Act requires employers to provide coverage for full-time employees, but not part-timers. That sounds like a straightforward and reasonable provision, but as usual the devil is in the details.

Surviving the 2015 AEP materials creation process

Debbie R. Mabari

The Centers for Medicare & Medicaid Services (CMS) recently released its model documents for the 2015 Annual Enrollment Period (AEP). The rigorous, highly complex rules and regulations for member marketing materials wreak havoc on health plans year after year. The clock is now ticking.

For expensive medications, collaborate on costs and outcomes

Mark Ballow, MD
Mark Ballow's picture

As health insurers adjust to a shifting regulatory landscape and changes in reimbursement, many have considered adopting restrictive formularies or new policies aimed at managing the usage of high-cost medications. While more restrictive formularies or policies for usage may temporarily cut costs, they can have serious health consequences for patients and can actually end up costing payers more in the long run.


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