Medecision’s Path Toward MARS-E Compliance
In January 2019, Medecision launched a yearlong process to achieve MARS-E compliance. Here’s how we did it.
Proposed Stark Law Changes Reflect Move Toward Value-Based Care
In October 2019, CMS proposed changes to the Stark Law, which was enacted in 1988 to prevent physicians from prioritizing financial concerns over patient care. Now, CMS says that changing…
CMS and ONC Interoperability Rules: What Do the Latest Updates and Enforcement Delays Mean for the Industry?
CMS and ONC delays to enforcement give the industry a few additional months to prepare for major overhauls to ensure the appropriate sharing of patient health information. Yet the need…
Leveraging Utilization Management to Reduce Medical Loss Ratio Rebates
Medical loss ratio (MLR) rebates hit a record $1.3 billion in 2019 because health plans spent too little on medical claims and too much on administrative costs. How can health…
Mitigate Compliance Risks by Addressing These Key Documentation and Billing Challenges for Medicaid Managed Care Plans
More state Medicaid programs are now addressing SDOH through managed care plans and Section 1115 demonstration waivers. However, while these Medicaid programs offer states the ability to experiment and innovate…
Automating Compliance in the Cloud
In his “Automating Compliance in the Cloud” session during the CTO Roundtable at Liberation 2019, Gerry Miller, the founder and CEO of Cloudticity, discussed the inherent benefits and challenges of…
New Rules From CMS Carry Heavy Weight for Payers
In February 2019, the Centers for Medicare and Medicaid Services (CMS) issued new requirements for Medicaid, the Children’s Health Insurance Program, Medicare Advantage plans and Qualified Health Plans, mandating they…
Risk Sharing Requires Health Plans to Hone Utilization Management Process
Healthcare organizations’ success under risk sharing and value-based care relies on a well-oiled UM program.
Addressing Social Determinants of Health Can Lead to Better Health Outcomes
Research shows that social determinants of health (SDoH)—such as housing, transportation, access to healthy food and more—are linked to patient outcomes. Managed care organizations are partnering with community and social…
“Utilization Management” is all about saving health plans money. Or is it?
Until recently, Utilization Management was all about how health plans determine preauthorization. But that definition is fast becoming outdated.
