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.

Transforming provider relationships is key to engaging consumers

Dianne Wagner, Florida Blue, and Carolyn Wukitch, McKesson

U.S. health plans today operate in a world of rising expectations. They must work to contain rising healthcare costs, while at the same time catering more to consumers as the ultimate users of their products, rather than solely satisfying the demands of employers.

RAPS, EDPS and risk adjustment: the health plan perfect storm

Dawn Carter, Edifecs

Commercial and government programs have witnessed a busy year -- most notably with the first year of commercial marketplace EDGE server data submission for risk adjustment; reinsurance coming to a close at the end of April; and the draft payment report being issued at the end of June.

All signs point to value-based care: Are you ready?

Daniel Finke, Aetna

With the current shift to value-based reimbursement, providers are facing noteworthy changes as healthcare consumers are under more financial pressure than ever before.

Setbacks and successes: What we've learned from the first year of commercial risk adjustment

Sean Creighton, Verisk Health

Qualified health plans completed their first year of commercial risk adjustment reporting and the Centers for Medicare & Medicaid Services reported the results.

CEO pay ratio rule, inequality debate could pressure healthcare

Anthony Brino

Though still a major source of middle class jobs, healthcare companies, including consolidating insurers and nonprofits, may need to find a way to afford raises for their lowest-paid employees.

Praluent is not like Sovaldi

David Williams

A few reasons why the want-to-be cholesterol blockbuster Praluent will not be as much of a “budget buster” as the medicine that cures most hepatitis C patients.

The less you know about health insurance, the harder it is to choose the right plan

Mary Politi, Washington University

Picking the right insurance plans for your budget and health needs is challenging. Weighing monthly premiums and co-pays against yearly deductibles and comparing the benefits different plans offer can make your head spin, especially if you are newly insured.

Making sense of new risk adjustment filtering logic

Sean Creighton, Verisk Health

CMS recently released the long awaited risk adjustment filtering logic for the Medicare Advantage Encounter Data Processing System, requesting comment by August 21. This logic is an important factor in the future of risk adjustment.

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