Current Trends For Payers

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Insider insights and perspectives on trending topics for healthcare professionals. We’re talking to the experts about the unique operating infrastructure necessary for business success and to improve the quality of care for members. Topics include BPaaS, technology, data security, operations, core administration, care management, member engagement, risk adjustment, HEDIS and Star quality measures, start-up and growth tactics, and regulatory and compliance. 

  1. 4월 24일

    The Cost of Inaction

    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 incremental fixes and point solutions are no longer enough, and how legacy operating structures can limit scalability, responsiveness, and strategic decision-making. At the same time, a shift is underway. A new operating approach is emerging—one that redefines accountability, integrates technology and operations, and introduces predictability into cost structures. What does this shift actually look like in practice, and how can leaders recognize when they’ve reached the tipping point? Listen to the full episode to uncover the signals, tradeoffs, and opportunities shaping the next era of payer operations. About Our Guest:  Ken Dixon works with health plans to determine their readiness to shift away from legacy operating models towards a modernized operating approach, demonstrating clear operational savings of 30-40% PMPM.

    23분

  2. 3월 18일

    The Hidden Economics of Payer Operations

    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 full operating picture is becoming a strategic priority for executive teams. If your organization is questioning whether incremental efficiency gains are enough to protect margins, this conversation offers an important perspective. Listen to explore the forces redefining payer operations and what they could mean for your plan’s financial future. About Our Guest: Missy Andersen is a healthcare operations and advisory leader with experience across consulting, regional health plans, and technology-enabled service models. She specializes in helping payer organizations evaluate their total cost of ownership, operational performance, and organizational design to support more efficient and sustainable operating models.

    16분

  3. 2월 19일

    Stars in Flux: CMS 2027 Changes

    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 the surface, they carry implications for how plans evaluate performance, align internal teams, and prepare for future contract years. The episode explores what these federal signals suggest about CMS’s direction and how plans can interpret them within the context of long-term strategy. What do these changes truly mean for 2027 and beyond—and how should payers respond now? Listen to the full episode to uncover the deeper strategic signals shaping the future of Medicare Advantage. About Our Guest: Shelby Jansen has deep expertise in guiding payer quality strategies to meet CMS expectations, reflecting NCQA updates, optimizing Stars and HEDIS programs, and guiding health plans through digital transformation.

    11분

  4. 1월 16일

    Lessons From 2026 Enrollment

    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 ahead. Tune in to understand how these changes affect the future of enrollment, and how leading plans are preparing now. About Our Guest: Alex Loera oversees the enrollment and billing operations aspect of the BPaaS ecosystem. He specializes in scaling enrollment and billing operations, improving data integrity, and strengthening compliance in high-growth, regulated environments.

    11분

  5. 2025. 12. 16.

    The Problem With Managing Multiple Vendors

    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 functions. Listen to discover how to drive lasting operational excellence with a single, accountable partner. About Our Guest:  Sean Cattie has deep expertise as a healthcare technology executive focusing on BPaaS delivery models. Sean leads client delivery teams responsible for technical capabilities, implementation governance, automation and configuration across enterprise operations.

    14분

  6. 2025. 11. 03.

    Pay Now or Pay Later—What Whistleblower Lawsuits Reveal About Risk Adjustment

    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-policy breakdowns, the message is clear: vendor oversight is a necessity. Listen now to uncover what these cases reveal and what your plan can learn from these whistleblower lawsuits. ABOUT OUR GUEST:  Kristi Reyes is the Director of Risk Adjustment Coding Operations. She leads a team of 250 medical coders from various aspects of risk adjustment—including retrospective, prospective, CDI, QA, risk mitigation, and RADV. Kristi holds Certified Professional and Outpatient Coding, Risk Adjustment Coding, and Auditing certifications.

    13분

  7. 2025. 10. 15.

    Bonus: Star Rating Report 2026

    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 HOS as a major performance driver.  This episode unpacks what changed, why it matters, and what payers must do now to avoid being left behind. Listen to uncover the real story behind the 2026 Star Ratings—and what it signals for 2027 and beyond. About Our Guest:  Shelby Jansen, Manager of Quality, Stars and Strategy, RHIA. Shelby has deep expertise in guiding payer quality strategies to meet CMS expectations, reflecting NCQA updates, optimizing Stars and HEDIS programs, and guiding health plans through digital transformation.

    14분

  8. 2025. 10. 01.

    Risk Adjustment Across Multiple Lines of Business

    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 grappling with audits, coding accuracy, or technology gaps, this conversation offers real-world insight and practical strategies for managing multiple lines of business (LOB). About Our Guest: Amanda Proctor has over 13 years in risk adjustment coding and specializes in risk mitigation, coding quality and education. She holds multiple certifications in coding and is an AAPC approved instructor.

    9분
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Insider insights and perspectives on trending topics for healthcare professionals. We’re talking to the experts about the unique operating infrastructure necessary for business success and to improve the quality of care for members. Topics include BPaaS, technology, data security, operations, core administration, care management, member engagement, risk adjustment, HEDIS and Star quality measures, start-up and growth tactics, and regulatory and compliance. 

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    2022년 - 2026년
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