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May 6, 2021

New rules would crumble “Berlin Wall” separating plan & provider data

Health plans and providers have traditionally operated in almost complete segregation, exchanging claims and authorization transactions but little else. Some of this separation stems from the adversarial relationship between “plans that pay” and “providers that cost.” This inherent division was expanded 20 years ago by the Health Insurance Portability and Accountability Act (HIPAA), shielding patient health information and demanding only the “minimum necessary” be exchanged between plan and provider trading partners.

Apr 1, 2021

COVID-19 vaccination monitoring: COVAX and considerations for Part D plans

The Centers for Medicaid and Medicare Services (CMS) plays an important role in facilitating access to COVID-19 vaccinations for Medicare recipients, protecting America’s senior citizens from COVID-19.  

Medicare Part D plans have an obligation to perform health care operations such as case management, care coordination or population-based activities to improve the health of their Medicare enrollees. For Part D plans to manage COVID-19 vaccine access and completion, those plans need to know when their enrolled Medicare members are receiving vaccinations.

Feb 5, 2021

Upgrading medicine through telehealth: true value for the dollar

Beginning in 2020, we have been seeing telehealth play a key role in providing care and filling access gaps for members/patients most at risk. The COVID-19 pandemic challenged the conventional health care models, as in-person office appointments became unfeasible due to strict social distancing guidelines and the need to reduce a patient’s risk of exposure. 

Dec 10, 2020

Prescription discount programs: 4 must-haves for third party administrators

The cost of healthcare is going up for large employers and their employees by an estimated 5% for 2021. Even though plan sponsors continue to shoulder a generous 70% of the cost per employee, rising prices—particularly in the pharmacy segment—mean that the out-of-pocket spending burden for employees won’t get any easier to manage this year.

Nov 10, 2020

Besting disruption during critical events: A new option for health plans

Health plans are in the business of dealing with unexpected events while making sure members have safe access to medical and pharmacy care. However, even with comprehensive contingency planning, disruptions can still place a strain on staff and resources. Events outside the realm of “business-as-usual” can pile up for health plans, creating new challenges around maintaining daily operations amidst multiple, serious disruptions.

Oct 27, 2020

Paper EOI – Digitized, automated, adjudicated – BRIX + Vidado

Group insurance carriers are under enormous pressure—from competitors, customers and the C-suite—to improve medical underwriting outcomes by investing in ways to increase EOI submission rates, automatic adjudication, real-time decisions and a mobile-ready experience.

Oct 2, 2020

Operationalizing RPA for the healthcare industry using Business Process Management

Robotic process automation, or RPA, can be an effective way to reduce costs while improving the quality of repetitive tasks. Because there is so much opportunity, the RPA software market grew more than 63% between 2017 and 2018. However, an astonishing 50% of RPA implementation projects fail. What sets the successful projects apart? Business process management.

Sep 23, 2020

HEDIS® MY2020 Data Management – Expanding Use of Electronic Clinical Data Systems

In the final blog in this series, I want to touch on the evolution of using electronic clinical data in HEDIS measures. Data collection is one of the biggest challenges health plans face in preparation for HEDIS measures. The Electronic Clinical Data Systems (ECDS) framework was designed to increase the efficiency of quality reporting while also providing an incentive to connect to primary clinical information systems. Organizations that successfully report ECDS measures demonstrate interoperability of health data systems in the provision of high-quality care. NCQA’s commitment to the ECDS architecture was bolstered by the standards for interoperability finalized earlier this year.


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