The Impact of Non-Compliance for Healthcare Organizations
In the intricate realm of healthcare, healthcare organizations confront the daunting challenge of adhering to stringent regulations. Non-compliance can precipitate severe financial […]
Critical Prep Areas for 2024 Utilization Management (UM)-Focused Audits
The 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) introduced new constraints on Utilization Management (UM) policies, particularly prior authorization, effective […]
FHIR® in Action: Streamlining Prior Authorization
Traditionally, prior authorization has been a complex, time-consuming process fraught with inefficiencies. Disconnected systems and manual procedures not only slow down care […]
Strategic Accelerations: Critical Business Initiatives for U.S. Healthcare Payers Part 2
In Part One of this series, we examined the initiatives Gartner identified as key areas for acceleration,1 following their extensive evaluation through […]
Strategic Accelerations: Critical Business Initiatives for U.S. Healthcare Payers Part 1
U.S. healthcare payers and third-party administrators (TPAs) face a complex array of business and technology initiatives driven by evolving market conditions and […]
Building Trust in Healthcare Payer Data: 3 Keys to a Reliable Data Quality Strategy
In the age of big data, healthcare payers and third-party administrators (TPAs) are overwhelmed by vast amounts of information, underscoring the importance […]
2026 CMS Interoperability and Prior Authorization: Key Strategies for Healthcare Payer Readiness
In January 2024, the Center for Medicare and Medicaid Services (CMS) issued the Interoperability and Prior Authorization Final Rule CMS-0057-F, heralding a […]
Facts About 2022 Medicare Advantage Plans
We find it fascinating how the Medicare Advantage industry changed exponentially in the past decade. With Medicare Advantage Plans now being a […]
Developing Care Management through Analytics
In today’s healthcare climate, where pay for performance and shared savings models are the new norm, using analytics creates the blueprint for […]
CMS Changes to 2021 & 2022 Star Ratings Data Calculations
The Centers for Medicare & Medicaid Services (CMS) announced it will “put patients over paperwork to provide temporary relief from many paperwork, […]