Payviders offer both insurance coverage and healthcare services to patients. This concept is a relatively new development in the healthcare industry, and it has the potential to significantly impact the way that healthcare is delivered and financed.
Health plan headaches begin with several challenges while navigating the rapidly evolving healthcare landscape. These challenges are driven by a combination of factors, including rising healthcare costs, regulatory changes, technological advancements, and shifting consumer expectations.
Payer Best Practices for Success: The healthcare industry is one of the most critical and rapidly evolving industries in the world. Healthcare payers, such as insurance companies, play an essential role in this industry by providing financial protection to individuals and families in the event of illness or injury.
NCQA Health Plan Accreditation is a rigorous evaluation process that assesses the quality of health plans and their ability to meet the needs of their members. As part of the accreditation process, NCQA requires health plans to undergo third-party review.
Prior authorization is a utilization management process used by some health insurance companies for determining if the patient’s health policy covers a prescribed services, like procedures, tests, or medications, before services are rendered. While intended to control healthcare costs, prior authorizations can be a significant burden on healthcare providers and can delay patient care.
No Surprises Act (NSA) protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.
Top At-Risk Conditions and utilization spikes that healthcare leaders and stakeholders across the industry must prepare to proactively address in the upcoming year highlight the recently released, 2023 State of Health – In The Aftermath Report. The report also presents predictive findings and explores the top contributing factors of many utilization increases.
Understanding the Vital Role, Challenges, and Opportunities of Independent Medical Review Services, offers a behind-the-scenes look at internal and external appeals, reasons why accredited IROs reduce risks, and a crash course on newer review services, such as the independent dispute resolution process that’s part of the No Surprise Act (NSA) surprise billing regulations.