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In the past 18 months, insurance providers have sought opportunities to counter the push back on prior authorization processes that have been criticized by insureds, providers, politicians and media outlets. While insurers argue that authorizations help reduce costs and avoid unnecessary care, providers and patients have argued that it creates artificial barriers to treatment and…

The new 2025 Star ratings are now out for Medicare Advantage-Part D (MA-PD) health plans, and only seven plans received a five-Star rating, down from 38 in 2024. About 40 percent of plans received four Stars or higher, and about 62 percent of MA members are enrolled in these plans. The average Star rating for…

In 1965, Medicaid was signed into law by President Lyndon B. Johnson as part of the Social Security Amendments and was authorized by Title XIX of the Social Security Act, which provided matching funds from the federal government to states to help them provide medical assistance to eligible residents. It plays a critical role in…

Good news for beneficiaries! Good news for Health Plans!!   On May 9, 2024,  CMS extended the Medicaid “unwinding” waivers into 2025. This means that the federal regulatory waivers and resulting options are now available until June of 2025. This continues to make available some of the methods states have been using to prevent administrative…

Introduction Health plans and providers need to ensure they understand their role in supporting CMS’ Strategic Plan related to the Quintuple Aim and the advancement of health equity, with an emphasis on data collection and reporting. The literature related to health equity frequently states that lack of data related to social determinants of health (SDOH)…

Even a cursory review of the latest healthcare news reveals that hospitals and health systems across the United States are looking to improve their financial outlook. With media headlines touting another round of layoffs at many health systems, the question becomes: Where and how can revenue cycle vendor partners step up to the plate and…

  Hospitals are operating in a world where they are being crushed by labor costs.  I talk to CFOs daily that describe unsustainable labor models they have been forced into.  As a result of this financial stressor, hospitals must scrutinize other costs, looking for savings.  Hospitals must purchase sutures, oxygen, and other mission critical needs,…

It has been a busy six months in the Medicare Advantage (MA) risk adjustment space, with plenty to keep the industry’s best and brightest thinking about what changes are in store for PY 2024 and beyond related to the risk model transition from v24 to v28, and the RADV Final Rule. Much of this prodigious…

Every hospital relies on a network of relationships with a variety of partners, including their patients and their support networks, local independent and employed physicians, state and federal organizations, payors, and many others. One of the most important relationships in driving growth, as opposed to other facility goals, is that with the local referring physician…