Category Archives: Health Plans

Specialty Rx: An exponential challenge for health plans

Health plans are seeing exponential growth in both the use and medical cost expense of specialty medications. In the past decade, the Food and Drug Administration (FDA) has approved more than 250 specialty medications. By 2020, specialty medications are estimated to cost $400 billion. Forty percent of that cost is expected to be paid under […]
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Keep a finger on the pulse of future CVD care

The years ahead will see greater challenges in cardiovascular disease (CVD) care. To prepare for what’s coming, providers and payers will benefit from working together to optimize quality of care and patient outcomes and lower the total cost of patient care. The relentless rise of cardiovascular disease CVD is the costliest chronic disease in the […]
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BPCI Advanced: March’s get-out-of-jail-free card

Has it been four months already? That’s when the first performance period began for CMS’ latest bundled payment model, BPCI Advanced. Now participants are less than a month away from the March 1st deadline. By March 1st, they can drop participation in any (or all) of the 32 clinical episodes without penalty or financial risk. […]
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Top outpatient surgery center trends in health care

Health plans are focusing on ambulatory surgery centers (ASCs) as a source of cost savings. The same procedure performed in an ASC may be less than it is in other outpatient ambulatory settings. Acute care facility inpatient admissions will gradually decrease as most health plans are moving services to the outpatient service facilities such as […]
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How the right HSA provider can support your employees’ health and security

Medical bills: trying to understand them may be nearly as painful as the injury or illness that generated them. This is an exaggeration, of course. But for many consumers, those bills can represent big problems, such as how to pay for their health care, how to plan for future care and how to achieve financial […]
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Next AI ‘wave’ will be a sea change for health care

The artificial intelligence (AI) journey from theory to mainstream has evolved in waves. While health care may see AI as an abstract concept, I believe that technology capabilities have already entered their second wave of evolution. The roots of artificial intelligence (AI) technologies go back to 1950, when Alan Turing suggested that machines could be […]
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What will you do differently this HEDIS® season?

Speaking from experience With limited resources during the short HEDIS season, health plans must make quick decisions to prioritize the number of medical records to retrieve, abstract and over read to meet their goals. One year when I was at a health plan, we were at the end of the HEDIS season. We were two […]
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Best practices to decrease growing emergency department costs

The costs of services provided by hospital emergency departments have become a source of major concern for payers. When a member receives care at an emergency department (ED), the facility and physicians separately submit evaluation and management (E/M) codes on the claim for services performed. E/M codes are based on services performed while caring for […]
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Not science fiction: AI is creating value in surprising places

You might think of artificial intelligence (AI) in health care as science fiction — something that’s a future possibility. But the truth is, the future is here now. AI is a collection of methods and technologies for performing tasks we often associate with the human mind, such as learning and reasoning. AI approaches already have […]
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Transforming payment accuracy with cloud technology and big-data culture

This is the second blog in our two-part series: “Payment Accuracy Gives CIOs an Opportunity to Self-Fund Transformation” An interview with Julie Durham, VP of Software Engineering and Payment Integrity, Optum Health plan CIOs balance efforts between “keeping the lights on” and evolving the digital ecosystem. Yet simple, early wins in payment accuracy can streamline […]
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