Implementing a new VBC program in healthcare requires cross-functional support and overcoming numerous challenges. Simplification opportunities exist to address pain points for program administrators such as rigorous research, ROI assessment, and stakeholder engagement. Manual processes, including participant recruitment, financial modeling, program integrity management, and technical assistance can benefit from technology to streamline and automate tasks, allowing skilled resources to focus on
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Healthcare Policy Regulation & Reform | News, Analysis, Insights - HIT Consultant
Demystifying Prepay Coordination of Benefits: A Crucial Component of Payment Integrity
Coordination of benefits (COB) is a key component of any effective payment integrity program. But determining primacy for members with multiple plans and ensuring claims aren’t overpaid can be a complicated process. Whether it’s verifying employment status or sifting through complicated claims, COB takes significant time for peak accuracy. And while health plans focus on the intricacies of an effective COB strategy, many overlook the possibilities that a comprehensive prepay COB solution can
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Reimbursement Shift under 2026 PFS Poised to Usher in New Era for RPM
The annual release of the Medicare Physician Fee Schedule (PFS) generated more attention than usual this year among practices that have considered or are already offering Remote Patient Monitoring (RPM) to their patients. CMS’s July 14 publication of the proposed rule, outlining revisions to payment policies and rates, was seen as particularly significant for RPM.
Key changes to RPM under the 2026 PFS include the introduction of a code for 2-15 days of data collection and another that allows
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Why Value-Based Care Fails to Reward LTPAC Providers Today
The chorus of voices singing the praises of value-based care is growing ever louder. But in LTPAC, it still feels like the system’s asking providers to do more—with less—and faster than ever.
For the past 25 years, financial strategy in long-term and post-acute care has been tied to two things: occupancy and payer mix. Around 70% of residents are covered by Medicaid. The rest—split between Medicare fee-for-service, Medicare Advantage, and private pay—bring in higher rates, especially
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How Online Resources Can Help Find the Ideal Therapist
Reaching out to a therapist is the first step to start the healing you deserve. Finding the right person for your journey can require more help than a typical Google search. If you’re ready to find a licensed mental health professional who can guide your growth, learn how to find a therapist with an online resource that makes the process easy.
Why Finding the Right Therapist Is Crucial
If you look up a therapist in your hometown, you may find several options. Although they could all have
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Guardrails for AI in Medicare Risk Adjustment: Navigating Innovation Without Losing Control
Implementing AI in Risk Adjustment for Managed Care is like adding rocket fuel to your engine—from accelerating chart reviews to identifying coding opportunities in near real-time, AI can dramatically improve efficiency, accuracy, and compliance. But without the right safeguards, the same tools can just as easily magnify errors, introduce bias, and create costly regulatory exposure.
As Managed Care organizations navigate this rapidly evolving landscape, a key question looms: How
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ACA Spillovers: A Warning for Employers as Insurers Seek Up to 43% Premium Hikes
What You Should Know:
- The U.S. healthcare market is showing a stark divergence in cost trends between public and private sectors. While Affordable Care Act (ACA) premiums are spiking well above the industry's decade-long trend of sub-10% increases, real-world claims data from self-funded employers show costs holding steady at under 5%, according to new data from Nomi Health.
ACA Rate Hikes Driven by Utilization and Risk
ACA insurers across the country are filing for some
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CMS Launches $50B Rural Health Transformation Program
What You Should Know:
- Today, the Centers for Medicare & Medicaid Services (CMS) unveiled details for states to apply for funding from the new $50B Rural Health Transformation Program.
- Created under the Working Families Tax Cuts Act, this unprecedented investment is designed to strengthen healthcare across rural America and build sustainable systems that improve access, enhance quality of care, and improve outcomes for patients.
Five Strategic Goals for Rural
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Medicaid Expansion: A Guide for Healthcare Providers to Prepare for Change
Medicaid is a lifeline for roughly 84.5 million people across the U.S., yet access to that safety net still depends on state lines. Ten states—Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming—continue to reject the Affordable Care Act (ACA) expansion, leaving an estimated 1.4 million adults in the infamous coverage gap. This category includes individuals whose earnings are too high for traditional Medicaid but still below the poverty level
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HHS Terminates California’s PREP Grant Over Refusal to Remove Gender Ideology Content
What You Should Know:
- The U.S. Department of Health and Human Services (HHS), through its Administration for Children and Families (ACF), has terminated California’s Personal Responsibility Education Program (PREP) grant.
-The termination follows California’s refusal to remove "radical gender ideology" from the federally funded education program, which is designed to prevent teenage pregnancy and sexually transmitted infections.
Rejecting Mandate to Change Sex-Ed
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