When AI investments fail to pay off, the problem is not lack of interest or excitement. It is the challenge of integrating AI into clinical workflows, building governance structures and earning clinician trust. Radiology offers a clearer path forward. Nearly…
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Health plans’ operations have historically been managed in silos, with each silo using different data. This has impeded efficiency and consistency for utilization management, payment integrity, member outreach, and other critical healthcare decision-making processes. Clinically trained automation solutions that use…
Last month, the Kansas State Employees Health Care Commission discussed the future of state employee health coverage — and there is a chance Blue Cross and Blue Shield of Kansas may not be in it. Under the current contract, state…
Major insurers continue to pull back from the ACA marketplace as enrollment declines, bronze plan uptake surges and the expiration of enhanced premium subsidies reshape the risk pool heading into 2027. 1. The latest exits Cigna will exit the ACA…
Sharon Williams, a management consultant who took over as president of the University of Michigan Health Plan as it wound down, thinks there is one imperative for tackling healthcare costs. “We will not be able to appropriately address cost until…
CMS plans to fine Health First Health Plans $43,546 for failing to properly administer Medicare’s Part D transition supply policy, according to an April 29 notice from the agency. The insurer, part of the Rockledge, Fla.-based health system, had a…
CMS is imposing a $48,833 fine against a Providence PACE organization in Napa, Calif., according to an April 29 notice from the agency. The penalty was issued to Collabria Care, the name under which Providence Community Health Napa Valley holds…
Every missed or under-documented diagnosis — malnutrition, pressure injuries, respiratory failure — costs hospitals an average of $10,000 in reimbursement per patient, while quietly inflating length of stay and readmission rates. Across a health system, these gaps compound into a…
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Hospitals spent $43 billion in 2025 chasing payments insurers already owed them. Payer tactics have grown more sophisticated, more automated and harder to detect — and many of the most financially damaging losses, including DRG downgrades, never trigger a formal…
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Many hospitals still rely on generic clinical risk scores to flag high-risk patients. The challenge: those scores aren’t built to map to how CMS Star Ratings, HRRP, VBP and Leapfrog measure performance — which means quality improvement effort can be…
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