By: Wes Morris, Associate Director, Optum Clinical and Quality Solutions The Five-Star Quality Rating System is an important part of the Centers for Medicare and Medicaid Services’ (CMS) goal to improve the quality of care and general health status for beneficiaries. For Medicare plans, the consequences of falling short of an overall 4-star rating can […]
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By: John Hoffman, Director, Application Managed Services Operations — Payment Integrity Software — Payment Integrity, OptumIT This is the 2nd blog in a 3-part series “Optimizing Payment Integrity software to avoid payment pitfalls” There is an art and science to effective claims adjudication. The science lies in more edits, which can drive 1–2% in cost avoidance. But […]
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By Dr. Aaron Cohen $1.3 trillion every year. That’s the impact of seven chronic conditions on the U.S. economy, according to a 2014 Milken study.1 Maybe it’s not surprising, given the human toll: nearly half of Americans suffer from at least one chronic disease. One in four lives with multiple chronic conditions. 2 According to […]
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By: John Hoffman, Director, Application Managed Services Operations — Payment Integrity Software — Payment Integrity, OptumIT This is the 1st blog in a 3-part series “Optimizing Payment Integrity software to avoid payment pitfalls” In the dynamic health insurance industry, the claims operations organization within a payer is committed to paying a provider’s claims as quickly and accurately […]
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A person with a chronic condition goes to his doctor, who prescribes medication to treat that condition. Simple enough, right? Yet 20–30 percent of the time, a person doesn’t fill their prescription. And about 50 percent of medications for chronic disease are not taken as prescribed. 1 Many don’t realize the consequences of non-adherence. When […]
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By: Erin Schmuker, Vice President, Product Solutions – Payment Integrity, Optum This is the final blog of our 2 part series “Maximizing post-payment recovery, preparing for pre-payment success“ Your transition to pre-payment success can be a natural extension of your post-payment efforts to create a comprehensive payment integrity strategy. How? The first step is to look […]
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By: Erin Schmuker, Vice President, Product Solutions – Payment Integrity, Optum This is the 1st blog of our 2 part series “Maximizing post-payment recovery, preparing for pre-payment success” There is an increasing focus on pre-payment. However, your organization may not be able to fully commit to a comprehensive payment integrity approach. Even the most robust […]
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By: Rob Mayer, Vice President, Product Strategy – Payment Integrity, Optum This is the final blog of our 3 part series “Uncover hidden funds with comprehensive payment integrity“ There are many talented payment integrity vendors. There are also many niche vendors that provide consultative, software-based or service-based solutions focusing on specific aspects of payment integrity. […]
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By: Rob Mayer, Vice President, Product Strategy – Payment Integrity, Optum This is the 2nd blog of our 3 part series “Uncover hidden funds with comprehensive payment integrity“ If you want to maximize your ability to recover inappropriate claim payments and overpayments and reduce administrative costs, a comprehensive payment integrity strategy will help you achieve […]
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Treating chronic kidney disease is expensive. A commercial health plan with 200,000 members may have about $16 million in costs. That averages out to about $260,000 per member.1 Along with inpatient admissions, the other main cost driver is dialysis. Many kidney patients never see a nephrologist before starting dialysis. Some don’t have symptoms in early […]
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