Payers

CMS grants quality reporting exceptions for facilities recovering from Hurricane Ida

The agency has granted certain Medicare quality reporting exceptions to healthcare facilities in areas of Louisiana, Mississippi, New York and New Jersey that were battered by Hurricane Ida. By providing the exceptions, CMS aims to enable facilities to direct their resources toward recovery.

Healthcare leaders share lessons learned addressing social determinants of health

Leaders with insurers and health systems said that taking a holistic approach and partnering with community organizations is key to standing up a successful social determinants of health program at a panel discussion hosted by MedCity INVEST Digital Health. 

CMS suspends enrollment in UnitedHealthcare, Anthem MA plans

The agency has suspended enrollment in three UnitedHealthcare plans and one Anthem plan for 2022 because the plans did not spend enough of their premium incomes on medical benefits and claims. The payers can contest the suspension, though it is unclear if they plan to.

CareFirst unveils virtual-first primary care practice

The practice, which initially will only be offered to CareFirst BCBS commercial members, provides an array of services, including preventive care, insurance navigation and behavioral and mental health services. Patients will be referred to in-person care with local providers when needed.

Hive is a new & potentially devastating type of ransomware. Here’s what you need to know.

This new type of ransomware — which was linked to a cyberattack against an Ohio-based health system in August — employs a multi-pronged approach, focusing not only on encrypting sensitive data but also on terminating backup processes to make it harder for organizations to recover from the attack.

INVEST Digital Health Preview: How Has RPM Reimbursement Evolved and Where Does it Need to Go?

INVEST Digital Health is set for September 20-23. Held in a virtual format due to Covid-19, the healthcare conference brings together innovative investors across the healthcare spectrum, prominent industry players and the most promising digital health startups.

Lawsuit: Aetna fertility coverage policy “an illegal tax” on LGBTQ people

The lawsuit alleges that an Aetna policy discriminates against LGBTQ people by requiring them to pay thousands in out-of-pocket costs for fertility treatments before becoming eligible for coverage. Though Aetna has agreed to pay the costs incurred by the plaintiffs, the suit aims to strike down the policy as a whole.

Analysis: Cost of care for unvaccinated Covid patients spikes to $5.7B

The cost of hospital care for unvaccinated Covid-19 patients has more than doubled, jumping from about $2 billion to $5.7 billion over the summer. And this figure may still be lower than the actual cost burden unvaccinated people represent to the healthcare system.

Babyscripts raises $12M, plans to expand to all 50 states

The maternal care startup is backed by major health systems including MemorialCare Health System, whose innovation arm led the most recent funding round. Babyscripts offers a mobile app providing education and resources for the pregnancy and postpartum journey.

New HHS proposed rule requires payers to disclose broker rates, share air ambulance data

In a set of newly proposed rules, HHS wants insurers offering individual and short-term, limited-duration coverage to disclose to members the rates they pay to brokers who help people select health plans. The government also wants to collect air ambulance data to help curb the high and unexpected costs that arise from these services.

We’re not out of the COVID woods yet. But what we’ve already learned is going to save millions of lives.

Covid-19 exposed serious weaknesses in the American healthcare system, and has taken an unfortunate personal and economic toll on the entire world. But in the end, I do believe that our healthcare system will emerge more accessible, affordable, and effective

How tech can help solve the overpayments problem in healthcare RCM

When CMS overpays for services, providers and commercial payers are responsible for paying the agency back, and at times, they are on the hook for millions of dollars. But technology can help healthcare stakeholders catch the mistakes that lead to overpayments, thereby reducing unnecessary costs.

Reducing low-value care starts by understanding its drivers

There is no single driver of low-value care — providers, systems, and patients all play a role. But with the right tools, stakeholders can work together to re-align incentives and transform our healthcare delivery system into one that prioritizes value, eliminates waste and leads to better overall patient outcomes.

Report: Medicare trust fund still expected to run out by 2026

The latest report from the Medicare Board of Trustees shows that the health insurance trust fund, also known as Medicare Part A, will run out in a mere five years, which is in line with reports released in 2018, 2019 and 2020, indicating that the Covid-19 pandemic has not hastened the fund’s depletion.

Sutter Health to pay $90M to resolve False Claims allegations

The California-based health system will pay a hefty price to resolve allegations that it knowingly submitted inflated diagnosis codes for certain Medicare Advantage beneficiaries to receive higher payments. Sutter Health does not admit any liability in the matter.

Report: Uninsured rate holds steady at 11% during pandemic despite job losses

The increase in access to public health insurance coverage — via legislation like the Families First Coronavirus Response Act that prevents states from disenrolling Medicaid beneficiaries — helped offset the loss of employer-sponsored insurance, the report from Robert Wood Johnson Foundation shows.

Trinity Health Mid-Atlantic to deploy NeuroFlow’s mental health tools across 3 hospitals

Through a program funded by Independence Blue Cross Foundation, 1,800 frontline healthcare workers across the three Pennsylvania-based hospitals will gain access to NeuroFlow’s technology, which will measure and track their mental health symptoms and provide support via educational resources and a clinical care team.

Analysis: Care for the unvaccinated may be costing U.S. healthcare system $2.3B

The report, released by Kaiser Family Foundation and the Peterson Center on Healthcare, details the high cost of Covid care for the unvaccinated. In fact, the analysis indicates the figure could be even higher than $2.3 billion, as the authors did not take into account the cost of outpatient treatment for Covid-19.

Insurer price transparency rule faces legal challenges: 4 takeaways

Two lawsuits, filed by the U.S. Chamber of Commerce and the Pharmaceutical Care Management Association, allege that portions of the price transparency rule governing insurers are unlawful and would drive up healthcare prices, contrary to the rule’s stated aim.

Reports: 1 in 10 adults delayed care in spring amid trailing healthcare utilization levels

According to two new reports, hospital admissions were about 85% of what was expected based on historic patterns at the beginning of April, and in the same month, 11% of adults reported delaying care because of Covid, including 16% of Hispanic and 13% of Black adults.

CareMax to add 50 new senior care centers through Anthem collaboration

The senior care provider currently operates 34 medical centers offering healthcare and social services, like transportation. Through the collaboration, the companies will bring more seniors into value-based arrangements with the goal of improving outcomes for Anthem patients.

How payers, providers are tackling homelessness & extending care access

Homelessness, a key social determinant of health, is on the rise, prompting action from payers and providers. Though their efforts are varied, ranging from subsidizing housing to making it easier for those living in encampments or temporary housing to access care, they have a common goal.

UnitedHealth subsidiaries settle mental health parity allegations for $15.6M

UnitedHealthcare and United Behavioral Health agreed to the settlement to resolve allegations that they illegally denied coverage for mental health and substance use disorder treatments. The allegations are related to business practices they no longer use, parent company UnitedHealth Group said.

HIMSS Digital: Future is bright for payer-provider-pharma collaboration

The pandemic made collaboration necessary between stakeholders that otherwise tend to be at odds with each other. But as partnerships grow, providers, payers and pharma companies must ensure they are working toward a clear-cut common goal, according to panelists at HIMSS 21 Digital.

Insurers back kidney care startup Cricket in $83.5M round

Cigna Ventures and Blue Shield of California contributed to a funding round for Cricket Health, a startup that provides services to help patients identify chronic kidney disease and get support in treatment. The investment was led by Valtruis, a firm that invests in value-based care companies.

CMS repeals MA rate disclosure requirement, boosts hospital payments by $2.3B

CMS has finalized its 2022 inpatient payment rule, which will not only repeal part of the price transparency requirements related to Medicare Advantage rates and increase payments to hospitals but will also require facilities to report Covid-19 vaccination uptake among its employees.

Justice Department joins False Claims lawsuits against Kaiser Permanente

The government has intervened in complaints alleging Kaiser Permanente entities defrauded Medicare out of “tens of millions of dollars” by knowingly submitting false diagnoses for Medicare Advantage beneficiaries. Kaiser denies the allegations, saying it is in compliance with program requirements.

Texas law eases prior auth burdens, but payers see it as a dangerous move

The law, which will take effect in September, prohibits payers from requiring pre-approval from certain providers. While providers believe the law will cut administrative burdens, and improve care delivery, payers say it could lead to patient harm.

BCBS of Kansas City sues Covid-19 testing provider over alleged price gouging

GS Labs, a Covid-19 testing provider, has submitted over $9.2 million in claims to the insurer as a result of its grossly inflated prices, the lawsuit states. The testing company rejected the claims, saying its “prices accurately reflect the level of service” it provides.

Automating authorizations as patients return to care

“The entire healthcare industry was turned upside down by the pandemic. Procedures were pushed back, insurance companies gave policy holders a lot of mixed information. It has been a mess.” This is what one healthcare executive told us when we surveyed patients and providers on the state of patient access, in June 2021. Changing prior …

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What insurers’ premium rate filings can tell us about predicted health utilization in 2022

An examination of health insurers’ premium rate filings for 2022 shows that most are not factoring in additional costs or savings, which indicates that they expect health utilization to reach pre-pandemic levels.

With eviction moratorium set to end, millions of people are still behind on rent

With the CDC’s eviction moratorium set to lift at the end of the month, many people are still struggling with rent payments and utility debt. Insurance and healthcare technology leaders shared how they’re preparing and what’s needed to address the housing shortage in the long term.

As independent practices vanish, experts debate the pros & cons of a consolidated market

Independent physician practices are being gobbled up by hospitals, payers and private equity, and while some see it as a boon for the practices and industry as a whole, others believe it will raise costs and block access to care.

Transforming rural healthcare will require a funding overhaul. Here’s one way to do it.

The answer to rural healthcare’s financial issues could lie in a payment model that pools funds from public and private insurers alike to pay for agreed-upon core services, allowing rural hospitals to provide the care most needed by the communities they serve.

Biden’s latest executive order aims to boost healthcare competition

President Joe Biden has signed a new executive order to tackle anti-competitive behavior across American industries. With regard to healthcare, Biden is directing federal agencies to revise guidelines for hospital mergers, enable people to comparison shop health plans on the ACA marketplaces and work with states to import drugs from Canada.

Study: Black, Hispanic beneficiaries driving MA enrollment growth

Enrollment in Medicare Advantage plans grew rapidly between 2009 and 2018, with the largest increases seen among Black, Hispanic and dual enrollee — that is enrolled in both Medicare and Medicaid — populations. This indicates that payers will need to play a key role in addressing health inequities.

UnitedHealthcare nixes some out-of-network coverage for non-emergencies

Per a policy update that went in to effect July 1, the health insurance giant is not covering non-emergency services that members receive at out-of-network facilities that are outside of their service area. This update mainly affects residential treatment facilities, inpatient rehabilitation and other non-hospital-based services.

Federal agencies issue rule enforcing surprise billing ban

HHS, along with other federal agencies, have released the first set of regulations that ban surprise billing and out-of-network charges for several types of services. More regulations are expected, especially those pertaining to the independent dispute resolution process that providers and payers will have to undergo if they cannot agree on out-of-network claims payment.

Job losses, federal regulations drove Medicaid enrollment to a historic high

Enrollment in Medicaid and the Children’s Health Insurance Program has reached a record high, with 80 million now covered through these programs. The spike was largely driven by the economic downturn brought on by the pandemic and a federal requirement that prevents states from removing people from the programs until the public health crisis is …

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CMS proposed rule aims to boost ACA enrollment, reinstate navigator duties

A new CMS proposed rule aims to make significant changes to Affordable Care Act marketplaces, including increasing the annual open enrollment period by a month and restoring the duties of navigators who help consumers from underserved populations enroll in plans on the federally facilitated exchange.

Building mutually-beneficial partnerships between payers and community-based organizations

The sustainable route to building a more integrated healthcare ecosystem is through partnerships. But for these collaborations to be successful, communication and clear financial incentives need to be aligned between payers and community-based organizations. 

Report: Hospitals, insurers, PE firms own nearly half of physician practices

The Covid-19 pandemic spurred the rate of physician practice acquisition by hospitals and corporate entities, like payers and private equity firms, a new report shows. As a result, by January 2021, about 48% of physician practices across the country were owned by one or the other entity.

Supreme Court upholds ACA, dismissing constitutional challenge

The Supreme Court upheld the Affordable Care Act, dismissing the lawsuit brought by Texas, 17 other states and two individuals on the grounds that they were not able to prove they were harmed by the law. Industry stakeholders celebrated the court’s long-awaited decision.

Data Reveals Institutional Racism in Healthcare Still Exist, But Providers/Payers Can Change That

Minal Patel, CEO of Abacus Insights The vaccine rollout is following patterns that are all too familiar —  but we can change that Newscasters sounded surprised when they announced for the first time that COVID-19 was disproportionately affecting Black, Indigenous, and people of color. As they presented graphs that showed higher rates of infection, hospitalization, …

Data Reveals Institutional Racism in Healthcare Still Exist, But Providers/Payers Can Change That Read More »

Could the answer to misaligned payer incentives be a futures market for health interventions?

Payer incentives are often not aligned with implementing interventions that will benefit patient health the most in the long term. Enter Nobil, which aims to create a healthcare futures market that invests in interventions with the greatest impact over time.

Kaiser Permanente, Centene, others join White House effort to boost vaccination rates

Several organizations, both providers and payers, have pledged to help the White House achieve its goal of administering at least one dose of the Covid-19 vaccine to 70% of Americans over the next month. These organizations are launching various initiatives to engage the unvaccinated, including call campaigns and financial incentives.

CMS ups Medicare payment for at-home vaccinations to about $75 per dose

CMS is increasing the payment for administering at-home Covid-19 vaccinations from around $40 to $75 per dose. The move comes amid the Biden administration’s push to boost vaccinations nationwide, including among older adults who may not be able to access vaccine sites.

Emergency physicians oppose new UnitedHealth policy enabling retroactive ED claims denial

UnitedHealthcare is instituting a new policy beginning July 1 that changes how the payer assesses emergency department claims, allowing it to retroactively deny ones it deems “non-emergent” or not an emergency. The American College of Emergency Physicians has made its opposition clear, stating the policy may violate federal law.

Report: Which US markets are ripe for ‘payvider’ models? 

“Payvider” models — that is, collaborative arrangements between payers and providers — are growing in popularity. But not all markets are created equal with regard to payvider adoption and growth. In a new report, consultancy firm Guidehouse identifies the markets with the most opportunities for payviders.

Study: Poor care access, higher costs more likely with private than public insurance

People with private insurance report poorer access to care, higher costs and lower satisfaction as compared to those with public insurance plans, a new study shows. As the debate over health insurance reform continues, policymakers should consider efforts that expand Medicare and increase protections for those with private insurance.

SCAN Health’s new program to tackle senior isolation focuses on connections with peers

To tackle loneliness among seniors — which can have serious repercussions on health — Medicare Advantage plan provider SCAN Health has launched a togetherness program. The program is founded on senior-to-senior interactions, both virtual and, eventually, in-person.

Coverage parity for mental health, substance abuse, a key focus for insurance regulators

Health insurers are prohibited from placing unfavorable limits on mental health and substance abuse benefits, and yet, many do. Federal and state regulators are taking aim at these practices and making the enforcement of the Mental Health Parity and Addiction Equity Act of 2008 a key focus.

UnitedHealthcare’s new social determinants effort spans 23 programs

The payer’s Community Catalyst initiative includes 23 programs that involve collaborations with various community-based organizations and health centers. They tackle different types of social determinants of health issues, including food insecurity among seniors and the health needs of those in public housing.

Anthem, Epic strike data exchange partnership

The EHR giant will integrate its payer platform with the insurer’s operating system to facilitate two-way data exchange with providers. Through this integration, the organizations hope to support clinical decision-making and streamline administrative processes like prior authorizations.

Bright Health follows rival Oscar Health down IPO path

Bright Health has filed preliminary paperwork for an IPO, joining its rivals in the insurance technology space in going public. Though there are few confirmed details at the moment, Bright Health is reportedly looking to raise $1 billion through the offering.

Report: Payers saw higher gross margins, lower loss ratios in 2020, indicating profitability

Payers appeared to have a profitable 2020, with gross margins per member per month increasing, and administrative costs and medical loss ratios decreasing, a new report shows. But payers still have to contend with rebates their owe per the ACA medical loss ratio provision, which could amount to more than $2 billion.

CMS’ rule granting speedy coverage to FDA-designated ‘breakthrough’ devices delayed again

CMS delayed the start date of its rule that would provide expedited Medicare coverage for products the FDA deems “breakthrough devices” from May 15 to Dec. 15. CMS wants more time to examine concerns expressed about the rule, including that devices may gain coverage despite limited evidence of their use among seniors.

Clover halves membership projections for direct contracting

When it planned to go public through a SPAC merger, insurance startup Clover Health told investors that it already had 200,000 direct contracting lives under contract for 2021. But in new guidance shared on Monday, the company now plans to end the year just 70,000 to 100,000 covered lives from direct contracting. 

Texas lawsuit: Biden administration threatening funding to force Medicaid expansion

Filed by the Texas attorney general, a new lawsuit seeks to prevent the Biden administration from revoking the Trump-era approval of a Medicaid waiver extension that could cost the state billions in funds. The revocation was a political move intended to force the state to expand Medicaid under the ACA, the lawsuit claims.

Oscar Health betting on +Oscar business as it posts net loss of $87M in Q1

Despite recording a net loss of $87 million in Q1 2021, the insurance startup’s leaders are optimistic about future growth, especially in light of the launch of +Oscar. A platform business, +Oscar generates revenue by making the company’s technology stack available to providers and payers.

Though training is necessary, payers see value in telehealth-first health plans

As demand for telehealth grew, payers accelerated their development of telehealth-first plans. Now that several have launched, it is clear that bringing these plans to market requires added effort on the part of payers, but they are here to stay.

Clover Health, Roundtrip to offer MA members non-emergency transport services

The health insurance startup and transportation service company are joining forces to offer Medicare Advantage members access to non-emergency medical transportation. With transportation being a key social determinant of health, Clover Health and Roundtrip are aiming to improve member experience and outcomes through the partnership.

Blue Health Intelligence, AnalyticsIQ to help fight health inequity by enhancing payer data

Together, the companies will add race, ethnicity and language information as well as social determinants of health factors to a database of millions of Blues plan members. The insights gleaned will be used to design interventions and develop community partnerships to reduce disparities in care.

Care.coach takes aim at senior loneliness with round-the-clock virtual pets

Armed with a tablet and virtual pet companion, California-based startup care.coach is aiming to alleviate senior loneliness — an issue that has worsened amid the Covid-19 pandemic. The company, which won the health IT track of the Pitch Perfect contest at MedCity INVEST, aims to fulfill seniors’ medical and social needs through access to health …

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Insurtech companies’ IT expertise give them competitive edge in telehealth & beyond

Insurance startups’ interest in telehealth is backed by both technical expertise and a focus on consumer experience. This will provide them a leg up not only in the competitive telehealth arena but also in consolidating other digital care services.

CMS finalizes new rules for ACA exchanges in 2022: 5 key provisions

CMS has adopted several new rules that will change how the Affordable Care Act exchanges operate next year. These include rules that will lower out-of-pocket consumer spending by $400 and widen eligibility for gaining health coverage outside of the designated ACA open enrollment period.

CMS’ price transparency rule offers providers, payers a win, too

Patients are not the only ones who will benefit from the price transparency rule — providers and payers can also gain competitive advantages as a result of the regulation. These include being able to deepen relationships with patients and support payment contract negotiations.

Top 5 Medicare Advantage plan changes coming for 2022

The greatest uncertainty is members’ health status, which could impact MA organizations’ bidding submission process for 2022. Fortunately, fully vaccinated members are likely to resume in-person care this year, which means MA plans can expect a more consistent and reliable stream of data to form financial projections.

Innovaccer Launches Enterprise Data Platform for Payers on the Innovaccer Health Cloud

What You Should Know: – Innovaccer, Inc., a San Francisco, CA-based healthcare technology company, has launched its Enterprise Data Platform for payers on the Innovaccer Health Cloud. – The solution will enable healthcare payers to accelerate digital transformation, facilitate interoperability, foster collaboration across stakeholders in the healthcare ecosystem, and comply with regulatory requirements. – Fragmented …

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BCBSA to take aim at racial inequities in health, starting with maternal care

The Blue Cross Blue Shield Association recently announced its new national health equity strategy that will focus on maternal health, diabetes, cardiovascular care and mental health. The association’s first goal is to cut racial disparities in maternal health by 50% in the next five years.

Like it or not, value-based contracting is coming for drugs and medical devices

Value-based contracts covering the reimbursement of drugs and medical devices are slowly gaining acceptance. A panel at the MedCity News INVEST conference discussed the challenges and opportunities for these contracts, which aim to improve patient outcomes and control the cost of care.

Stanford Health Care seeks up to $1.9M from Anthem in new suit

The California-based provider has filed a lawsuit against the payer, claiming Anthem has yet to pay for the care it provided to patients covered by its affiliate. Stanford and Anthem had an implied contract, and if it is not upheld by the court, the provider is seeking $1.9 million in reimbursement.

Providers, payers are ready to listen, root out racism and regain the trust of minorities. Here’s how.

Racism has always existed in healthcare, but the Covid-19 pandemic laid bare how entrenched the problem still is. In response, providers and payers have vowed to fight for health equity by examining the racism within their organizations, listening to minority communities and mounting strategies that take aim at widening care gaps.

Illinois first state to offer full Medicaid benefits to women one year postpartum 

As part of its ongoing effort to improve maternal outcomes in the country, the government has approved Illinois’ request to extend full Medicaid coverage for new mothers. The approval extends the coverage from 60 days to one year and will give about 2,500 women living below the poverty line access to care every year.

Cohere Health Raises $36M to Automate Prior Authorization Between Payers & Providers

What You Should Know: – Boston-based health IT company Cohere Health has closed a $36 million Series B funding round led by Polaris Partners, with additional participation from new investors Longitude Capital and Deerfield Management, as well as existing investors Flare Capital Partners and Define Ventures. The round comes less than a year after the company launched, and only 3 months after …

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Q1 2021 Health IT/Digital Health PC/VE, M&A, IPOs/ SPACs Activity

The first quarter of 2021 has been one of investor optimism as the vaccine rollout continues ahead of expectations and economic activity begins to accelerate in response.  Within the Health IT industry, the already strong investment and M&A trends seen in 2020 have only accelerated.  Over the course of the quarter, we observed $7 billion in private …

Q1 2021 Health IT/Digital Health PC/VE, M&A, IPOs/ SPACs Activity Read More »

Does Telemedicine Impede or Help the Patient-Centered Medical Home?

Traditional patient care patterns have been radically altered by the COVID-19 pandemic. And after more than a year of disruption, it’s doubtful that everyone will revert to those patterns after the pandemic. New habits have been formed, and consumers are more willing to pursue the path of least resistance in obtaining care, such as opting …

Does Telemedicine Impede or Help the Patient-Centered Medical Home? Read More »

Centene refutes Ohio AG’s lawsuit, says it reflects misunderstanding of Medicaid billing

Centene has rebutted the accusations made in a sealed lawsuit filed by the Ohio attorney general that accused the insurer of over-billing the state’s Medicaid department. The lawsuit is based on a misunderstanding of how Medicaid billing operates and should be unsealed, Centene said.

How a Virtual Care Mindset Leads to Greater Patient Acceptance and Sustainable Telehealth Growth

Sandeep Pulim, MD, Chief Medical Officer at Bluestream Health There’s no question that the demand for telehealth and virtual care has grown exponentially over the last twelve months. With that growth has come a fundamental shift in the attitude toward virtual care. No longer do patients and providers take a “let’s try it” approach—now, it’s …

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Lawsuit: Like a “boa constrictor,” UnitedHealthcare squeezed anesthesia group out of competition

U.S. Anesthesia Partners has filed lawsuits against UnitedHealthcare in Colorado and Texas, accusing the payer of forcing it out of network and intentionally interfering with its relationships with providers in those states. But, according to UnitedHealthcare, the lawsuits are an attempt to get the insurer to meet the anesthesia group’s high rate demands.

Report: Bright Health eyes $1B IPO

Insurance startup Bright Health is reportedly planning to raise up to $1 billion in an IPO that will be launched in the second quarter of 2021. The company, which provides several insurance products as well as an IT platform, could be valued at more than $10 billion, Bloomberg reported.

Boost Operational, Clinical and Financial Performance with Good Data

Peter Nelson, VP & General Manager, Global Alliances at GHX There’s an old adage that every challenge is merely an opportunity in disguise. COVID-19 highlighted the healthcare industry’s ongoing challenge with producing clean, standardized data. As the industry looks to rebound from the severe financial impact of the pandemic, there’s a renewed urgency among hospitals …

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COVID Exposed The Dire Need for Real-Time Healthcare Data Sharing

Birju Shah, Head of Product for Uber Health & Communities Nick Jordan, Founder and CEO, Narrative In a world where technology and Big Data can provide us with instantaneous access to our banking transactions, and our financial information and credit reports can be retrieved with a few keystrokes when applying for a mortgage — trying to …

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With telehealth, pharmacy offerings, Amazon starts to encroach on PBMs

As Amazon starts to roll out its telehealth and pharmacy offerings, most big health systems and insurers don’t yet view it as a threat. But pharmacy benefit managers and vertically integrated payers will be keeping a watchful eye on the company as it starts to encroach on a slice of their business. 

To Advance Health Equity, Put Real-World Cancer Data to Work

Dr. Miller, Medical Director of CancerLinQ LLC Despite decades of scientific progress against cancer, access to treatment remains highly unequal. Some of the reasons — like institutional racism and poverty — are a reflection of our broader society. Other inequities may go unrecognized but are no less damaging. People with underlying health conditions, for example, …

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Epic-Humana partnership enters new phase focused on prior authorizations

The partnership between the insurer and EHR giant — announced a year and a half ago — will now focus on streamlining prior authorizations and offering providers enhanced insights about their patients. Ochsner Health will be among the first to implement the new capabilities offered by the companies.

NeoGenomics Acquires Precision Oncology Platform Trapelo Health for $65M

What You Should Know: – NeoGenomics, Inc., a provider of cancer-focused genetic testing services and global oncology contract research services announced it has reached an agreement to acquire precision oncology platform Trapelo Health for $65M. The agreement purchase price of $65 million, consists of $35 million in cash on hand and $30 million in NeoGenomics …

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Apriss Health Acquires Care Coordination Platform PatientPing

What You Should Know: PatientPing, a comprehensive care collaboration platform, today announced that it has entered into a definitive agreement to acquire Appriss Health, a cloud-based care coordination software and analytics solutions focused on behavioral health and substance use disorder. – Together, PatientPing and Appriss, backed by Clearlake Capital Group, L.P. and Insight Partners, will represent the largest and most diverse care …

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AppliedVR Lands $29M for VR Platform to Treat Chronic Pain

What You Should Know: – AppliedVR, a Los Angeles, CA-based company advancing the next generation of digital medicine, today announced $29 million in Series A funding, bringing its total funds raised to date to $35 million. The round, which includes key investors F-Prime Capital, JAZZ Venture Partners, Sway Ventures, GSR Ventures, Magnetic Ventures and Cedars-Sinai, …

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Innovaccer Launches Provider Network Management Solution for Payers on the Innovaccer Health Cloud

–  Innovaccer, Inc., a leading healthcare technology company, announced the launch of its Provider Network Management solution to assist healthcare payers access complete view and exercise control over their provider network performance. – The Provider Network Management solution is powered by the Innovaccer Health Cloud and an integrated, modular, flexible platform that centralizes data and …

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Avoid legal pitfalls in developing innovative physician-hospital payment structures

While Covid-19 requires physicians and hospitals to be more efficient than ever, a number of legal structures must be considered before providers consolidate their resources. To optimize patient care and ensure rapid payment for services, avoid running afoul of these sometimes counterintuitive regulatory schemes.

Biden’s American Rescue Plan Act aims to bolster the ACA. Here’s how.

President Joe Biden recently signed the $1.9 trillion Covid-19 relief package into law. The American Rescue Plan Act includes several provisions to boost coverage under the ACA, like widening eligibility for premium tax credits.

Providence-Backed Tegria Acquires Healthcare IT Consulting Firm Cumberland

What You Should Know: – Tegria today announced the acquisition of Cumberland, a leading healthcare IT consulting and services firm for payers and providers. Financial details of the acquisition were not disclosed. – The acquisition accelerates the growth of Tegria, launched by Providence in October 2020 to provide next-generation technologies and services to the healthcare …

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Centene’s “corporate greed” led it to allegedly overcharge Ohio’s Medicaid department

The Ohio attorney general has filed a lawsuit alleging that a Centene subsidiary, which provides Medicaid services in the state, hired multiple companies to administer pharmacy benefits in order to inflate costs. As a result, the state’s Medicaid department paid millions in overcharges.

Aetna accuses Mednax of destroying evidence in overbilling suit: 5 things to know

In a lawsuit filed three years ago, Aetna alleged that Mednax had overbilled for medical procedures and services. Now, the insurer is accusing the medical group of destroying evidence pertaining to the suit and has asked a federal court to sanction Mednax.

Insurers sue ‘pharma bro’ Martin Shkreli, company for alleged price gouging

Blue Cross and Blue Shield of Minnesota has filed a class-action lawsuit — on behalf of itself and insurers from 30-plus states — against Martin Shkreli and Vyera Pharmaceuticals. The suit alleges the defendants intentionally monopolized the market for Daraprim to raise the price of the drug by more than 4,000%.

Meet Circulo, the insurtech firm on a mission to disrupt Medicaid managed care

A new startup has entered the highly competitive insurtech market — with $50 million in new funds. Circulo, co-founded by Olive CEO Sean Lane, is a Medicaid managed care company that plans to build a platform to improve care delivery and member experience.

Payers Struggle with Provider Data Management Too

Eric Demers, CEO of Madaket Health Provider data management is usually discussed from the provider perspective: the busy staff, the needless paperwork amid a pandemic, the faxing, emailing and uploading of data. In these scenarios, the health plans are often painted as the villains for their bureaucratic processes and unique requirements. But the reality is …

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Geisinger Health Plan, Tomorrow Health partner to make getting home care supplies easier

Per the partnership, Geisinger Health Plan’s half a million members will gain access to Tomorrow Health’s services, which focus on coordinating medical supplies for home-based care. Tomorrow Health’s platform connects patients to medical equipment suppliers and guides them through the purchase process.

Health Gorilla Nabs $15M to Expand FHIR-based APIs for Digital Health

What You Should Know:  – Health Gorilla raises $15M to scale its FHIR-based API solutions for digital health and expand into new markets.  – Health Gorilla will introduce new APIs to enable consumer access to medical records, payer-to-payer data sharing, and data quality assessments.  Health Gorilla, a Sunnyvale, CA-based provider of healthcare APIs, today announced …

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Innovaccer Reaches $1.3B Valuation, Launches Health Cloud Platform

What You Should Know: – Innovaccer closes Series D round of growth capital bringing Innovaccer at a total valuation of $1.3 billion. – In addition, the company has launched the Innovaccer Health Cloud, a platform as a service that combines the company’s Data Activation Platform and application suite with an extensive set of platform services …

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11 Best Practices of a Successful Care Model Transformation Plan

Moha Desai, Principal, Healthcare Strategy & Transformation  Health systems across the country will require a plan to react to government deep spending cuts and revenue shortfalls due to the COVID-19 pandemic. Hospital services have seen a significant downturn in demand in 2020, and the recent resurgence in cases has led to further decreases. The public …

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Humana, IBM Watson Health team up to provide access to AI chatbot

Through a new collaboration, Humana’s Employer Group members will gain access to IBM Watson Health’s AI-powered digital assistant. The chatbot will provide information on member benefits, claims, referrals and cost estimates for medical services.

Mercy, Anthem ink agreement to enhance care, drive down costs

The Missouri-based health system and payer have entered into a new cooperative care agreement that aims to reduce costs while improving both outcomes and patient experience. The agreement includes a closer alignment between clinical care and reimbursement as well as increased data flow between Mercy and Anthem.

Insightin Health gains $12M to help payers engage, retain members

Insightin Health aims to help payers retain and engage their members via its proprietary platform. The funding round was co-led by the Blue Venture Fund, a collaboration between Blue Cross Blue Shield companies, the Blue Cross Blue Shield Association and Sandbox.

Why hospitals want CMS, FTC to examine two UnitedHealthcare policies

Two UnitedHealthcare policies have raised several concerns among providers, including that they may display anti-competitive behavior and could block patient access to certain healthcare services. The American Hospital Association is asking the FTC and CMS to review and potentially block these policies.

UPMC Enterprises’ latest spinout uses natural language processing to enhance care quality

Astrata, a spinout of UPMC’s innovation arm, has developed natural language processing tools that can help providers and payers adhere to quality measures. This can, in turn, help healthcare organizations bolster their finances as reimbursement is increasingly being tied to these measures.

Healthcare Can Save $16.3B Automating Administrative Transactions, Report Finds

What You Should Know: – Each year, the US healthcare industry spends $39 billion on 9 administrative transactions, according to a new report from CAQH. – The 2020 CAQH Index also uncovered that by automating these transactions, the industry could save $16.3 billion annually–a 42% cost reduction. CAQH, released the eighth annual report measuring the …

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Short seller targets insurance startup Clover in scathing report

After a scathing report from short-seller Hindenburg claiming that Clover faced a False Claims Act investigation, the insurance startup’s stock plummeted. Clover went public last month after merging with a special-purpose acquisition company under billionaire investor Chamath Palihapitiya.  

Highmark expands access to device that helps manage panic, PTSD symptoms

The payer is expanding access to Freespria’s digital device that aims to eliminate or reduce symptoms of panic disorders and post-traumatic stress disorder. The expansion will give Highmark’s managed Medicaid and Medicare Advantage members access to the device as well as to telehealth coaching on how to use it.

A Patient Engagement Strategy Needs to Deliver a Holistic Experience

Chris Evanguelidi, Director, Enterprise Healthcare Market for Redpoint Global Inc. Researchers from Johns Hopkins published a study in October on the impact of the pandemic on health care delivery. Among its findings, the data show a 21.4% decrease in primary care visits in Q2 of 2020, compared against the average volume of Q2 visits for …

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Healthcare Metadata Management: 3 Critical Capabilities to Creating A Unified, Automated Approach

Amnon Drori, CEO of Octopai The healthcare industry, like many others, has become a data driven industry collecting data from patients, doctors, labs, and payers that are all crucial to patient healthcare diagnosis and outcome. When it comes to research, data can be useful in creating emerging healthcare technological innovations, pharmaceutical discoveries, as well as …

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Sharecare Acquires AI-Enabled Digital Transformation Platform doc.ai

doc.ai logo What You Should Know: – Sharecare acquires doc.ai to expand its engineering expertise, accelerate digital transformation of healthcare through innovative AI platform for an undisclosed sum. – Founded in 2016, the company licenses AI modules and creates products for a portfolio of clients, including payers, pharma and providers. – As part of the …

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MetroHealth System, Care Simple, Epic Launch Remote Patient Monitoring Program

What You Should Know: – Care Simple, Epic, and MetroHealth System announced that they have entered into a strategic remote patient monitoring integration partnership. – Under the terms of the agreement, CareSimple will empower the Cleveland, Ohio public health system with simple, patient-friendly RPM solutions to improve health outcomes for their high-risk senior and chronically …

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Insurtech startup Sidecar Health’s valuation hits $1B  

The new startup unicorn’s insurance product enables members to shop for medical services and pay directly for care. The company raised $125 million in a recent funding round, boosting its valuation, which it will use to increase its footprint and launch new products.

How a unique patient identifier gets health plans closer to interoperability

Health plans have been fighting against inaccurate member data, incomplete member profiles and duplicate records for years. Without a watertight way to keep track of patient identities so health data is reliably linked and accessible across multiple services, payers can’t always be confident that the record in front of them matches the member they have …

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Aledade Secures $100M for Value-Based Primary Care, Reaching $2.1B Valuation

What You Should Know: – Aledade raises $100 Million in Series D funding to help more primary care practices thrive in value-based care. – The new funding will power the growth of a nationwide network of more than one million patients by further expanding into Medicare Advantage Contracts. Aledade, a Bethesda, MD-based provider of value-based …

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3 Steps to Maintain Telehealth’s Momentum Post-Pandemic

In the face of COVID-19, healthcare witnessed how crises can become the long-awaited push for creativity and innovation that the industry needs. When our healthcare infrastructure’s weaknesses were exposed, telehealth helped to stitch them up, with the number of telehealth claims increasing 8,336% nationally from April 2019 to April 2020. Out of need, patients quickly …

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Healthcare PE Firm Heritage Group Launches $317M Health Tech Fund

Partners David McClellan, Rock Morphis, Paul Wallace (Left to Right) What You Should Know: – Healthcare private equity firm Heritage Group launches a $300M fund to invest in high-growth healthcare services and technology companies. – Heritage is backed by some of the leading healthcare organizations in the nation, including large provider systems, payers, and healthcare …

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New CMS rule to enable immediate coverage for FDA-designated ‘breakthrough’ devices

The agency has finalized a rule that allows it to provide immediate Medicare coverage for FDA-approved products that are deemed “breakthrough devices.” The new coverage process would enable seniors to get access to these devices more quickly, but some provider and payer groups are concerned that this could cause patient harm.

NeuroFlow Secures $20M for Tech-Enabled Behavioral Health Integration Platform

What You Should Know: – NeuroFlow raises $20M to expand its technology-enabled behavioral health integration platform, led by Magellan Health. – NeuroFlow’s suite of HIPAA-compliant, cloud-based tools simplify remote patient monitoring, enable risk stratification, and facilitate collaborative care. With NeuroFlow, health care organizations can finally bridge the gap between mental and physical health in order …

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Net Health Acquires Post-Acute Analytics Platform PointRight – M&A

What You Should Know: –  Net Health acquires post-acute market analytics platform PointRight to deepen the company’s analytics capabilities, post-acute presence, and support for SNF networks. Net Health, a provider of cloud-based software for specialty medical providers across the continuum of care, today announced that it has acquired PointRight Inc., a leading provider of analytics …

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COVID-19 Deferrals Lead to 3 Major Conditions Payers/Providers Must Address in 2021

What You Should Know: – COVID-19 care deferrals lead to three major boomerang conditions that payers and providers must proactively address in 2021, according to a newly released report by Prealize. – COVID-19’s hidden victims—those who avoided or deferred care during the pandemic—will increasingly return to the healthcare system, and many will be diagnosed with …

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Xealth’s CEO Shares Impact of Digital Health in 2020 and What’s Ahead in 2021

Mike McSherry, CEO & Co-founder of Xealth HIT Consultant sat down with Mike McSherry, CEO, and co-founder of Seattle-based digital prescription platform Xealth to discuss digital health lessons learned in 2020 and what we can expect in 2021. As Xealth’s CEO, Mike also works with Duke Health, UPMC, Atrium Health, and The Froedtert & the …

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4 Quick Tips for Getting COVID-19 Claims Paid Promptly

Lillian Phelps, Sr. Director of Product Management, Availity As the COVID-19 pandemic has gripped the world, many providers have adopted an all-hands-on-deck approach and mentality for treating COVID-19 patients, stretching their resources to the breaking point.  We have heard about the frontline heroes who have sacrificed their own health and safety to treat patients and, …

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UnitedHealth Group’s Optum, Change Healthcare to combine in $13.5B deal

Optum, a subsidiary of insurance giant UnitedHealth Group, agreed to buy healthcare technology company Change Healthcare for $13.5 billion in cash. The acquisition will add data analytics, research and revenue cycle management offerings to Optum’s service roster.

UnitedHealth Group Acquires Change Healthcare to Combine with OptumInsight for $13B

What You Should Know: – UnitedHealth Group has reached an agreement to acquire Change Healthcare in a deal valued at more than $13 billion, marking the first major acquisition of 2021. – Change Healthcare will be combined with OptumInsight to advance a more modern, information, and technology-enabled healthcare platform. UnitedHealth Group’s has reached an agreement …

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Centene to bolster behavioral health services with $2.2B Magellan Health acquisition

The insurer will pay $95 per share in cash to acquire Magellan Health, a company providing an array of services, including pharmacy benefit management and behavioral health and employee assistance program services. The companies aim to develop a behavioral health platform.

2020’s Top 20 Digital Health M&A Deals Totaled $50B

Teladoc Health and Livongo Merge The combination of Teladoc Health and Livongo creates a global leader in consumer-centered virtual care. The combined company is positioned to execute quantified opportunities to drive revenue synergies of $100 million by the end of the second year following the close, reaching $500 million on a run-rate basis by 2025. …

2020’s Top 20 Digital Health M&A Deals Totaled $50B Read More »

CIO: 3 Rules for Meeting ONC/CMS Interoperability, While Improving Cybersecurity

Scott Galbari, CTO, Lyniate Drew Ivan, Chief Product and Strategy Officer, Lyniate Healthcare data security has been a growing concern for CIOs for the last year or so, as hackers are increasingly targeting health information. Now, with a global pandemic forcing a shift to telemedicine and remote work, and new rules from the ONC and …

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30 Executives Share Top Healthcare Predictions & Trends to Watch in 2021

As we close out the year, we asked several healthcare executives to share their predictions and trends for 2021. Kimberly Powell, Vice President & General Manager, NVIDIA Healthcare Federated Learning: The clinical community will increase their use of federated learning approaches to build robust AI models across various institutions, geographies, patient demographics, and medical scanners. The sensitivity and …

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MedCity INVEST Precision Medicine spotlight: Building a BioInnovation Hub (video)

The panel, What It Takes To Build A Successful, Regional BioInnovation Hub (sponsored by Independence Blue Cross) focuses on Philadelphia — one of many cities seeking to support the continued growth of cell and gene therapy and connected health industries.

Information of nearly half a million Aetna members exposed in email hack

An email hacking incident exposed the information of close to 500,000 Aetna health plan members, the payer reported to HHS last week. The incident occurred when an unauthorized person gained access to an email account of Aetna’s vision benefit services provider.

Regence, MultiCare Health System to Deploy HL7 Da Vinci Member Attribution List for Value-Based Care Arrangements

What You Should Know: – Regence and MultiCare ink first-in-the-nation value-based care partnership to deliver improved health outcomes at lower costs. Health insurance provider Regence and MultiCare Health System, an independent accountable care organization (ACO) have partnered to deploy a first-in-the-nation value-based model that delivers better health outcomes to members at lower costs while simplifying …

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Gaps in Clinical Communication, Document Exchange Lead to Gaps in Care

John Harrison, Chief Commercial Officer of Concord Technologies Communication problems and inadequate information flow are two of the most common root causes of medical errors. The potential for miscommunication and faulty exchange of information in healthcare is substantial.  Consider: patient information is dispersed among multiple providers and payers along the continuum of care. Electronic Health …

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12 Recently Launched COVID-19 Vaccine Management Solutions to Know

An in-depth look at twelve recently released COVID-19 vaccine management solutions as COVID-19 vaccines are being distributed nationwide. 1. Microsoft Microsoft launches a COVID-19 vaccine management platform with partners Accenture and Avanade, EY, and Mazik Global to help government and healthcare customers provide fair and equitable vaccine distribution, administration, and monitoring of vaccine delivery. Microsoft …

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Intermountain, UnitedHealthcare create ACO for Medicare Advantage members

The health system and payer will coordinate care for eligible Medicare Advantage patients through the ACO, with the aim of improving health outcomes and reducing costs. The ACO expands a long-standing relationship between the two entities.

Why healthcare orgs are joining an effort to create 1M jobs for Black Americans

The newly created organization, dubbed OneTen, aims to create 1 million jobs for Black people over the next decade. Its founders include some big names in healthcare, such as Cleveland Clinic, Intermountain Healthcare and Humana.

Kaiser Permanente tests referring patients to 6 digital mental health tools

The managed care company picked six mental health apps that it made available to its members over the past two years. It recently published a paper showing patients were more likely to download or use digital health tools when referred by a physician.

CMS proposed rule requires payers to streamline prior authorizations

The rule would require payers in the Medicaid, CHIP and QHP programs to build and maintain application programing interfaces to improve data exchange and the prior authorization process. But the rule does not include Medicare Advantage plans, which the American Hospital Association called “disappointing.”

DispatchHealth Launches New Clinic Without Walls for Enhanced Virtual Visits to MultiCare Patients

What You Should Know: – DispatchHealth launches Clinic Without Walls, a new service line offering patients a telemedicine visit with in-person assistance for more complex medical visits. – The initial service line will be available in a pilot to MultiCare patients in the Tacoma and Spokane areas in an effort to its senior patients’ alternative …

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LeenTaaS Secures $130M for ML Platform to Help Hospitals Achieve Operational Excellence

What You Should Know: – LeanTaaS raises $130 million in Series D Funding to strengthen its machine learning platform to continue helping hospitals achieve operational excellence during a time where they are facing mounting financial pressures due to COVID-19.  – LeanTaaS provides software solutions that combine lean principles, predictive analytics, and machine learning to transform …

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A proliferation of genetic testing options brings new challenges

In the last 20 years, access to genetic testing has expanded significant as technology has advanced. But there’s still lots of work to be done to get tests covered and make them more accessible, panelists said at a virtual conference hosted by MedCity News.

CMS’ new Geo care delivery model: 5 things to know

The new Geographic Direct Contracting Model aims to improve quality of care and slash costs for Medicare beneficiaries across an entire region. It involves setting up risk-sharing arrangements where participants will be responsible for the total cost of care for beneficiaries in the region.

M&A: Olive Acquires AI Prior Authorization Company Verata Health

What You Should Know: – On the heels of $225.5 million dollars in funding and a $1.5B valuation this week, Olive today announced its acquisition of Verata Health to create a combined AI prior authorization solution for providers and payers under the Olive name. – Prior authorization is a $31 billion dollar issue in healthcare, …

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Recent Executive Hires: CVS Health New President, Cleveland Clinic/Amwell Joint Venture Leadership, Others

Neela Montgomery, EVP & President at CVS Pharmacy/Retail CVS Health Corporation names Neela Montgomery Executive Vice President and President of CVS Pharmacy/Retail, effective November 30, 2020. Montgomery will oversee the company’s 10,000 pharmacies across the United States. Montgomery, currently a Board Partner at venture capital firm Greycroft, most recently served as chief executive officer of …

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COVID-19: How Can Payers Prepare for Mandates and Support Pandemic Relief Efforts

Elizabeth Bierbower, Former President of Humana’s Group & Specialty Division Healthcare can achieve optimum efficiency when patients are at the center of care. When patients have the necessary information to navigate their care journey, they will choose the path to high-quality care at the lowest costs. Cost-sharing and insurance premiums are rising consistently since the …

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