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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Medicare Insurance| Regulatory, Policy, Patients Analysis, Insights - HIT Consultant
CMS Launches “Crushing Fraud Chili Cook-Off” Challenge to Combat Medicare Fraud with AI
What You Should Know:
- The Centers for Medicare & Medicaid (CMS) has launched a new market-based research challenge called the Crushing Fraud Chili Cook-Off Competition. The goal of the competition is to use explainable artificial intelligence (AI) and machine learning (ML) models to identify anomalies in Medicare Fee-for-Service (FFS) claims data that can be translated into new indicators of fraud.
- The challenge also seeks scalable technologies that can reduce
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Whistleblowers Accuse UnitedHealthcare/Optum of Medicare Fraud, Denying Critical Care to Nursing Home Patients
What You Should Know:
- Less than a week after the resignation of UnitedHealth Group (UHG) CEO Andrew Witty, two whistleblowers have come forward with significant evidence alleging that Optum, a subsidiary of UnitedHealthcare (UHC), is engaged in dangerous and deceptive practices amounting to defrauding Medicare.
- The accusations detail a purported "playbook" employed by UHC that systematically delays or outright denies critical care to vulnerable nursing home patients to
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The Health IT Needed to Implement Harris’ Medicare Home Care Proposal
Vice President Harris’ proposal to expand Medicare to include home care for seniors and people with disabilities could potentially provide up to 20 hours of weekly in-home care. The eligibility requirements for recipients is that they must face challenges with daily activities or suffer from serious cognitive impairments like Alzheimer’s.
Given this could potentially open up access to home care to millions of Americans who currently can’t afford to pay for it, will undoubtedly place an
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Healthpilot and Publix Partner to Simplify Medicare Plan Selection for Seniors
What You Should Know:
- Healthpilot, an AI-powered Medicare comparison platform, and Publix Supermarkets have joined forces to simplify the process of choosing Medicare plans for seniors.
- Publix Pharmacy customers can now access Healthpilot's comparison tool directly through the Publix website to review and compare Medicare Advantage and Part D prescription drug plans where Publix Pharmacy is a preferred pharmacy and Healthpilot is affiliated.
Addressing the Complexity of
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Connie Health Acquires Keen Insurance Services, Expands Reach to Empower Seniors in Navigating Medicare
What You Should Know:
- Connie Health, a Boston-based tech-enabled Medicare navigation platform, today announced that it has acquired Keen Insurance Services, a company built at Redesign Health.
- The acquisition will strengthen Connie Health’s commitment to expanding its reach and helping seniors across the U.S. make informed healthcare decisions.
Meeting the Growing Demand for Personalized Medicare Guidance
This strategic acquisition comes at a time of significant
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JAMA: Traditional Medicare Is, In Fact, The Failure
What You Should Know:
- A new article published in JAMA Internal Medicine reignites the debate about Medicare Advantage and traditional Medicare.
- Dr. Sachin H. Jain, CEO of SCAN Group and SCAN Health Plan, argues in favor of Medicare Advantage, while Drs. Adam Gaffney, David Himmelstein, and Steffie Woolhandler advocate for traditional Medicare.
Traditional Medicare: Lower Costs, Fewer Benefits
Traditional Medicare offers beneficiaries lower premiums, but it comes with
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M&A: MultiPlan Acquires Benefits Science LLC for $160M
What You Should Know:
MultiPlan, a provider of data-enabled cost management, payment, and revenue integrity solutions for 700+ healthcare payors announced the acquisition of Benefits Science LLC (BST) for $160M in cash and stock.BST was founded in 2012 by a group of MIT-trained experts in data science, including Dimitris Bertsimas, Ph.D., who is recognized as an early pioneer in healthcare analytics and who serves as the company’s chief data scientist. Dr. Bertsimas will continue with BST
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Healthy.io Secures $50M to Expand Smartphone Kidney Test
What You Should Know:
Healthy.io, the global leader in transforming the smartphone camera into a clinical-grade device, raises $50M in a Series D funding round led by Schusterman Family Investments and is joined by Aleph and other existing shareholders. This investment, together with a previously unannounced $45 million February 2022 investment, comprises the company’s Series D.The Series D round will support Healthy.io’s expansion across the U.S. market, where Minuteful Kidney™, the
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Improving Non-Emergency Medical Transportation: Driving Better Outcomes for Patients and Health Plans
As the healthcare industry continues to evolve, there is a growing need for innovative solutions that not only improve the quality of care but also make care more accessible. Non-emergency medical transportation (NEMT) plays a crucial role in helping patients get to where care is delivered. As healthcare reform efforts continue to gain momentum, transportation benefits have become an increasingly critical component of providing equitable care to patients. NEMT helps close the health equity gap
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