Current Trends For Payers

Rising margin pressure, regulatory demands, and fragmented operations are forcing health plans to confront a difficult question: when does maintaining the current model become more expensive than changing it? This episode examines the often-overlooked cost of inaction—where financial strain, delayed growth opportunities, and operational complexity quietly compound over time. It explores why increm...

Administrative costs are climbing across the payer industry, but many plans still rely on high-level expense views that mask the true drivers of operational spend. Beneath the surface, fragmented systems, manual processes, and vendor complexity may be shaping financial outcomes more than leaders realize. This episode takes a closer look at how hidden cost dynamics emerge and why understanding the...

Medicare Advantage organizations are facing a significant policy year as CMS releases updates that signal a recalibration of the Stars program and broader regulatory framework. Recent rule-making and guidance point to changes in measurement priorities, simplification efforts, and evolving expectations around quality performance and operational execution. While some updates appear administrative on...

Enrollment for 2026 brought major shifts for health plans, driven by new CMS rules, rising consumer expectations, and the growing pressure to modernize operations. This episode explores how plans are rethinking enrollment integrity, broker oversight, digital shopping, data quality, and how emerging interoperability requirements will reshape eligibility, provider data, and automation in the seasons...

Is managing multiple vendors slowing your health plan down? Disconnected systems, rising costs, and scattered data often stand in the way of efficiency and better member experiences.  This episode explores the challenge of managing multiple vendors and how health plans can escape this antiquated operating model to simplify operations, cut costs, and gain real-time visibility across business functi...

Whistleblower lawsuits are pulling back the curtain on risky coding practices and costly compliance gaps in risk adjustment. From inflated RAF scores to vendor oversight failures, the consequences are real and growing. This episode unpacks several DOJ cases that reveal how coding shortcuts, unsupported diagnoses, and non-compliant queries can escalate. From internal governance gaps to coding-polic...

The 2026 Medicare Advantage and Part D Star Ratings are out—and they reveal more than just who earned 5 stars. Beneath the numbers lies a clear message: CMS is reshaping what quality means, shifting the balance from member satisfaction to measurable outcomes and data precision. Plans that once thrived on experience scores are now facing tougher cut points, new ECDS-only measures, and the rise of H...

Navigating risk adjustment across multiple lines of business isn’t just complex, it’s a balancing act of shifting regulations, diverse populations, and evolving models. In this episode, we break down the key differences between Medicare Advantage, Medicaid, and ACA, and explain why understanding these nuances is crucial for health plans that manage all three simultaneously. Whether you’re grapplin...

What if your contact center could do more than answer questions? What if it could predict needs, detect fraud, translate languages in real time, and coach agents as they speak to members?  In this episode, explore how AI is transforming call centers into strategic experience hubs. From agent assist tools that streamline workflows to virtual agents that replace outdated IVRs, we dig into the innova...

This season on Current Trends for Payers , we’re highlighting guest experts in emerging technologies and operational strategies that health plans need to stay agile and competitive. We’ll dig into what’s working and what’s coming next, with candid conversations from executives, product, and business leaders. Whether you're focused on risk adjustment, member engagement, or core admin, this sea...

Health plans continue to face operational delays due to fragmented systems and an over-reliance on manual reporting cycles. While data analysts work across multiple platforms to produce static reports, the insights often arrive too late to support real-time decisions. This episode explores why traditional models are no longer sustainable and how self-service dashboards, powered by a connected data...

CMS has issued a major announcement that’s reshaping how Medicare Advantage plans approach risk adjustment audits. A new era of oversight is here. Defined by tighter timelines, expanded audit scope, and heightened expectations around data accuracy. Along with the announcement, a detailed compliance memo introduces new submission deadlines that demand immediate attention from health plans. This shi...

In this episode, we explore how data consolidation is reshaping health plan operations and why it is becoming essential for the future of the industry. From breaking down data silos to enabling real-time, data-driven decisions, data hubs offer health plans a scalable solution to improve efficiency and streamline processes. Discover the challenges health plans face today and how a data-centric ecos...

Payers are seeking new ways to enhance member engagement and drive long-term retention.  This podcast explores a powerful new-to-market strategy for transforming how health plans design member journeys to create a seamless experience in a combination of offline and online environments.  Don’t miss the insights in this episode that will redefine how your plan approaches member engagement. About Our...

Claims and enrollment management can feel like a juggling act, especially with rising volumes and the pressure to meet strict accuracy and timeliness standards. What if there were tools to simplify it all? In this episode, we dive into the game-changing power of modern workflow solutions. Discover how these tools eliminate inefficiencies, prevent cherry-picking by claims and enrollment processors,...

Health plans often underestimate the full financial burden of their core administration systems. This episode shines a light on the hidden costs buried and spread throughout the lifecycle of a typical core admin vendor contract. We will discuss what total total cost of ownership is, how to evaluate it, and what to do when costs are unexpectedly higher than you anticipated due to spread-out expense...

Clinical documentation improvement (CDI) is essential for accurate patient care, compliance, and effective risk adjustment. Health plans and providers must work together to address common challenges like incomplete records, workflow disruptions, and slow technology adoption. By integrating solutions that fit seamlessly into provider workflows—whether through EMR-compatible platforms or flexible en...

In this episode, we discuss the history of tech ecosystems for health plans, the most common operating model today, the multiple-vendor model, and an innovative new operating model that relies on an end-to-end ecosystem from a single, accountable vendor partner. We discuss the pros and cons of the different models, as well as provide recommendations for future-forward plans that are ready to impro...

Accurate coding in healthcare is critical, especially with the recent changes brought about by the RADV extrapolation rule. This regulation allows the Office of the Inspector General (OIG) to apply audit findings from a sample across an entire Medicare Advantage plan, significantly increasing the financial risks associated with coding errors. For example, a $500,000 penalty for mistakes in coding...

This episode explores the challenges and opportunities plans face during the digital transition. The most common challenges are outdated systems, fragmented data sources, and managing data integration effectively. We discuss innovative strategies to reshape HEDIS reporting and analytics—from integrating diverse digital data into a unified platform to accelerating processing speeds for real-time in...

The 2025 Medicare Advantage and Part D Star Ratings were released on October 10, 2024. This year brought significant shifts that will impact health plans across the industry. With new challenges in place and more stringent performance measures, it’s essential for health plans to understand how these changes have affected Star Ratings. The introduction of updated methodologies, such as the use of E...

Preparation and a vigilant organizational mindset are critical to reducing the financial and reputational risk of cybersecurity incidents.  Join CISO, Hans Guilbeaux for an in-depth discussion on ways health plans can ensure their vendors have implemented industry best practices and are prepared for incident response with detailed disaster recovery and business continuity processes. About Our Gues...

Retrospective risk adjustment involves several administratively heavy processes, from chart retrieval to coding to supplemental data and submissions. The ever-changing regulatory environment requires continual updates in processes and technology. Join expert Greg Pastor to discover ways to streamline retrospective risk adjustment processes and develop a strategic, multi-faceted approach to address...

While prior authorization serves as vital checks and balances, ensuring clinical quality and preventing fraud, the administrative burden it imposes on providers and payers alike has led to an industry-wide reevaluation of certain codes and an increased push towards technology for auto-approvals and Gold Carding. Now, it's up to payers to encourage provider adoption of the technology by offeri...

As payers adopt artificial intelligence (AI) technologies in different aspects of healthcare operations, there is a need for AI governance and the careful vetting of vendor AI practices to safeguard patient welfare.  AI solutions can offer valuable decision support to create efficiencies at scale, timeliness, and accuracy. However, AI solutions should not run autonomously, nor should the final res...