Payer Operations
Expert articles and analysis related to payer operations.
AI Summary — Last 7 Days
Medicare Advantage operations are tightening on multiple fronts: CMS’s 2027 MA landscape shows a modest contraction in plan count and sharper benefit redesign, with major carriers reducing footprints, dental allowances, and premium givebacks as they prioritize margin recovery over growth—creating disruption for beneficiaries and network/value-based partners in markets like Minnesota (Healthcare Dive). At the same time, risk adjustment and utilization management are under heightened pressure: Independence Blue Cross agreed to a $22.5M settlement over alleged inaccurate MA diagnoses, HHS is defending MA audit methodology in court, and CMS’s WISeR model is advancing AI-enabled prior authorization scrutiny for selected Medicare services—signaling that MA revenue integrity, documentation discipline, and post-acute/utilization management will be central operational risks for VBC organizations (Fierce Healthcare
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The House has gone home until after midterms, and the Senate has one foot out the door. In the meantime, let’s take a spin around the Beltway and see what’s percolating with the administration’s healt...
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