• How virtual companions can close care gaps and reduce costs

    Payers face multiple industry headwinds, ranging from healthcare worker shortages to the high prevalence of chronic conditions, disjointed member experiences and disengaged members. These headwinds result in gaps in care, unnecessary emergency department (ED) readmissions and other issues.
  • Viewpoint: Federal Medicaid work requirements are unconstitutional

    Forcing states to implement Medicaid work requirements would fail basic constitutionality tests, a group of health policy experts wrote in Health Affairs. 
  • Pennsylvania bans out-of-pocket costs for breast cancer screenings, genetic testing 

    Pennsylvania Gov. Josh Shapiro signed legislation May 1 that will require all payers operating in the state to eliminate any out-of-pocket costs for annual breast cancer screenings and genetic testing for high risk individuals.
  • State audit questions CalOptima's surplus funds, hiring practices

    California regulators raised concerns about hiring practices and a surplus of funds at CalOptima Health, a managed care plan with nearly 1 million members. 
  • Payers are concerned about gene-therapy drug costs: 5 things to know

    Payers are anticipating the cost of expensive new gene therapy drugs to be a significant issue in the coming years, according to a survey from the Pharmaceutical Strategy Group. 
  • 26 state attorneys general urge Medicare to cover Alzheimer's treatments

    Twenty-six state attorneys general are asking Medicare to cover monoclonal antibody treatments for Alzheimer's disease. 
  • Georgia signs state-run ACA exchange into law

    Georgia Gov. Brian Kemp signed legislation May 2 that establishes a state-managed ACA exchange, pending approval from CMS.
  • Montana judge halts rule requiring prior authorization for Medicaid-paid abortions

    A Montana judge is temporarily halting a rule that would require prior authorizations for Medicaid-paid abortions, the Daily Montanan reported May 1. 
  • UnitedHealthcare ordered to pay Envision $91M in billing dispute

    Arbitrators sided with physician services company Envision Healthcare in its dispute with UnitedHealthcare over allegations the payer breached their contract by reducing reimbursement rates. 
  • Medicare Advantage in the headlines: 7 recent updates

    Bright Health is moving to sell the last of its Medicare Advantage business, and new enrollments are boosting payers' first-quarter earnings. 
  • How Blue Cross Blue Shield of Arizona is changing behavioral health numbers and narratives

    I have held titles throughout my life and career that reinforce my commitment to healthcare and caring. I’m the chief medical officer at Blue Cross Blue Shield of Arizona, former director of the Arizona Department of Health Services, and above all – I’m a mom. 
  • Medicare Advantage enrollment has surpassed traditional Medicare

    Medicare Advantage enrollment has surpassed traditional Medicare for the first time in the program's history.
  • Clover Health's 5 highest-paid executives

    Clover Health CFO Scott Leffler was paid $13.5 million in total compensation in 2022, according to regulatory filings published April 26. 
  • Oscar Health's highest-paid executives

    Oscar Health interim CFO Siddhartha Sankaran was the company's highest-paid employee in 2022, according to regulatory filings published April 27. 
  • UnitedHealth in the headlines: 12 updates

    From releasing its first quarter earnings to its Optum arm purchasing a multispecialty physician group, here are 12 UnitedHealth updates Becker's has reported since April 10:
  • Post-discharge: A critical moment for health plans to support caregivers

    Hospital stays – particularly for seniors and patients with complex care needs – are stressful and overwhelming. Hospital discharge processes are confusing and insufficient. And, that is rarely the end of the challenge. When someone is discharged from the hospital, they often return to their home in a new state of “normal” — one with likely escalated vulnerability and support needs.
  • More enrollees choosing higher-premium Medicare Advantage, Part D plans

    The average premium cost for Medicare Advantage plans sold on eHealth increased from $6 a month in 2022 to $9 in 2023, according to the online insurance marketplace's annual "Medicare Index Report." 
  • 4 ways ChatGPT can boost health insurance processes

    ChatGPT has made headlines across healthcare in recent months, and insurers are no exception to organizations that can use the tool to automate and streamline internal and external processes.
  • Molina reports $321M profit in Q1

    Molina Healthcare reported double-digit growth in net income since the same period last year and raised its year-end earnings guidance, according to the company's first-quarter earnings posted April 26.
  • AI and clinical data: The future of UM transformation

    At Becker's Hospital Review's 2023 Payer Issues Roundtable, Olive’s UM Business Unit, which is now part of Availity, sponsored an executive roundtable to explore how AI and clinical data can streamline utilization management and create a foundation for broader healthcare transformation efforts. Led by Matt Cunningham, Executive Vice President, Product, leaders in attendance from health plans across the country shared their thoughts and engaged in an exciting discussion. Four key takways were: AI is more than a single technology. AI isn't simply robotic process automation, natural language processing (NLP) or statistical modeling. NLP, for example, can surface words, but it can't interpret them. An implication in a healthcare setting is that NLP could find data related to A1C scores, but it won't be able to isolate trends in the data. "True AI, when used well, takes advantage of multiple technologies. It thinks as a human, helping you make decisions and move forward with your business,” Mr. Cunningham said. With AI, the healthcare sector can practice better medicine and more effectively engage patients. In the next few years, healthcare organizations will be using AI to automate workflows, enabling employees to operate at higher capacity levels. "There's an opportunity here to restore the human touch, not just the artificial touch," Mr. Cunningham said.Experts believe that those organizations that vigorously apply AI over the upcoming decades will dominate their industries. To make the AI journey more successful, a recent Harvard Business Review article recommended that organizations utilize a technology partner, apply AI throughout the enterprise, integrate AI solutions into workflows and become more data driven. Utilization management is the on ramp to the clinical data highway. Utilization management (UM) is the only lever that allows payers to mandate the collection of data across all programs. The current approach to UM, however, has many flaws. Most decisions are rendered with no clinical data and the process creates heavy network abrasion.In contrast, the UM Solution collects clinical data, scores it against medical policy and automates UM workflows. "By using a clinical data-first approach, you can create a very different experience," Mr. Cunningham said. In about 80 to 85 percent of cases today, prior authorizations are approved. If you can automate that work, human intelligence can focus on the 15 to 20 percent of cases that are complex and need a more thorough review. Our philosophy is to use UM as the foundation for building a clinical intelligence platform that enables healthcare organizations to make decisions based on clinical data and drive deeper insights from the data. The UM Solution reduces UM turnaround time from days to seconds. A payer recently implemented the UM Solution to support three programs that account for the majority of the organization's prior authorizations. 78 percent are resolved without human touch. "The average turnaround time used to be 2.5 days; now it's a matter of seconds,” Mr. Cunningham said. As healthcare continues to rapidly evolve, the organizations that thrive will be those that use AI effectively throughout the enterprise. The UM example shows what is possible when using AI and clinical data to dramatically improve UM efficiency and the manual labor associated with prior authorization.UPDATE: This Roundtable took place prior to the Availity acquisition of Olive's UM business. Learn more about the acquisition here: Availity Acquires Utilization Management Solution and Business Unit from Olive.

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