healthaxis

In Part One of this series, we examined the initiatives Gartner identified as key areas for acceleration,¹ following their extensive evaluation through research surveys and interactions with U.S. healthcare payer business and technology executives.

U.S. healthcare payers and third-party administrators (TPAs) face a complex array of business and technology initiatives driven by evolving market conditions and increasing consumer demands. Successfully navigating this dynamic landscape requires a clear understanding of how to manage these challenges effectively.

In the age of big data, healthcare payers and third-party administrators (TPAs) are overwhelmed by vast amounts of information, underscoring the importance of data quality. A robust data quality strategy is essential, as it guarantees the accuracy and relevance of the collected data, thereby informing decision-making and strategic planning processes. This approach not only enhances operational efficiency but also supports the delivery of high-quality member care.

In January 2024, the Center for Medicare and Medicaid Services (CMS) issued the Interoperability and Prior Authorization Final Rule CMS-0057-F, heralding a transformative phase for U.S. healthcare payers effective January 1, 2026. This pivotal rule revises the landscape of prior authorization (PA) processes, especially for Medicare Advantage (MA), Medicaid, Children’s Health Insurance Program (CHIP), and Marketplace plans, signifying a major operational shift for healthcare payers.

We find it fascinating how the Medicare Advantage industry changed exponentially in the past decade.

With Medicare Advantage Plans now being a primary partner, we have put together this infographic based on reports provided by KFF Reporting and CMS to show you what to expect from Medicare Advantage in 2022.

This month we are spending some time with Alex Morrison, Solutions Architect to learn about his daily activities and team accomplishments and challenges in the past few months.  

In today’s healthcare climate, where pay for performance and shared savings models are the new norm, using analytics creates the blueprint for sound care management.  

The Centers for Medicare & Medicaid Services (CMS) announced it will “put patients over paperwork to provide temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, Medicare Advantage, and Part D plans, and States can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.”

This month, we are connecting with Andy Parker, Director of Administration Services about his department projects, team, and client relations. 

MA plans must still offer all enrollees uniform benefits, premiums and cost sharing.

“Under the bipartisan budget deal signed by the president in February, Congress expanded supplemental benefits for the chronically ill to include those that “have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee and may not be limited to being primarily health related benefits.” The law also authorizes CMS to waive uniformity requirements, but only with respect to supplemental benefits for enrollees with chronic conditions. As healthcare’s focus shifts increasingly to population health, barriers such as transportation and food and housing insecurity are entering the equation of what it means to be and remain healthy. Without a reliable ride, for example, patients may miss scheduled appointments or fall treatment regimens, increasing the likelihood of more costly care in the future.” Read the full article.