Payer

Value-based care programs generate no shortage of insights. The problem is turning those insights into action, consistently and at scale. As downside risk grows, organizations face thousands of coordinated tasks across quality, care management and utilization management. Manual outreach, siloed…

More than 60 percent of U.S. adults report difficulty accessing timely primary care, driving delayed treatment, higher downstream costs and avoidable escalation. Primary care access gaps are growing, and payers are increasingly looking to AI-enabled models to close them without…

Today’s group health market is defined by complexity: rising costs, changing risk profiles and heightened expectations from brokers and employers alike. Carriers need more than standalone risk scores; they need complete visibility and control. But too many are stuck with…

HEDIS season shouldn’t require all-hands-on-deck for months at a time — yet many health plans report rising burnout, staffing strain and mounting pressure to hit quality targets with fewer resources. Leaders need a way to stay ahead of deadlines without…

Members want more from their health plans: clarity, affordability and support before health concerns become crises. But many plans are still stuck in reactive mode. This on-demand conversation, recorded live at Becker’s Fall 2025 Payer Issues Roundtable, explores how leading…

Health plans are under growing pressure to improve accuracy, accelerate recoveries and reduce waste. AI is helping meet that challenge — not by replacing workflows, but by making them more intelligent and responsive. By analyzing structured and unstructured data, from…

Medicare Advantage continues its rapid growth, with over 32.5 million enrollees in 2024—now representing more than half of the eligible Medicare population. [source] As the older adult population expands, payer organizations face the critical challenge of delivering highly personalized, quality care at…

CMS mandates for interoperability, patient access and prior authorization — CMS-9115-F and CMS-0057-F — are fundamentally changing how payers and providers must share data, with enforcement deadlines extending into 2026. The good news: Compliance doesn’t necessarily require ripping and replacing…

AI is flooding healthcare, but not all of it improves outcomes or deserves trust. For payer leaders overseeing utilization, case management and other clinical operations, the question isn’t whether to adopt AI — it’s how to evaluate the right kind.…

AI is flooding healthcare, but not all of it improves outcomes or deserves trust. For payer leaders overseeing utilization, case management and other clinical operations, the question isn’t whether to adopt AI — it’s how to evaluate the right kind.…