25 episodes

Insider insights and perspectives for healthcare executives of government-sponsored health plans. We’re talking to the experts about the unique operating infrastructure necessary for profitability and improving quality of care and member experience. Topics include technology, data security, operations, care management, member engagement, risk adjustment, quality measures, start-up and growth tactics, legal and regulatory. 

Medicare Advantage For Health Plans Sponsored by UST HealthProof & Advantasure

    • Government
    • 5.0 • 10 Ratings

Insider insights and perspectives for healthcare executives of government-sponsored health plans. We’re talking to the experts about the unique operating infrastructure necessary for profitability and improving quality of care and member experience. Topics include technology, data security, operations, care management, member engagement, risk adjustment, quality measures, start-up and growth tactics, legal and regulatory. 

    Why Retrospective Risk Is Administratively Heavy—And What To Do About It

    Why Retrospective Risk Is Administratively Heavy—And What To Do About It

    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 addressing industry changes.About Our Guest: Greg is the Managing Director of Risk Adjustment Operat...

    • 12 min
    Prior Authorization Trends & Opportunities

    Prior Authorization Trends & Opportunities

    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 offering platforms with user-friendly interfaces, intuitive design, and seamless workflows. Streamlining pri...

    • 12 min
    Responsible AI For Payers

    Responsible AI For Payers

    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 result go unquestioned. It is essential that all stakeholders understand how AI solutions draw t...

    • 17 min
    Unlock The Potential of Prospective Programs

    Unlock The Potential of Prospective Programs

    As more and more provider organizations enter into risk-sharing agreements, provider engagement programs are experiencing a surge in participation. Provider engagement programs improve the collaborative relationship between plans and providers to keep documentation up-to-date for CMS submission. It's essential for plans to offer a variety of delivery methods to suit the provider's practice. Some practices enjoy an in-person, on-site method to receive personalized guidance for education and to...

    • 21 min
    NLP For Coding & Compliance

    NLP For Coding & Compliance

    NLP is an AI technology that is being used in healthcare IT for clinical documentation and medical coding. For medical coding, the program identifies diagnoses codes for HCC risk adjustable categories and flags it for a medical coder to review. In robust medical charts that span up to thousands of pages in length, this enables coders with an automated way to identify diagnoses codes for review, hence increases speed, efficiency, and output. Academic research has found NLP increases medic...

    • 16 min
    RADV—The Future of Reimbursement Accuracy

    RADV—The Future of Reimbursement Accuracy

    The intention for developing RADV audits was to develop a checks and balances to ensure reimbursement payment accuracy for Medicare Advantage Organizations (MAOs). There’s a history of CMS addressing payment accuracy in the Medicare space that dates back to the 80’s with the prospective payment system, PPS, and in the late 90’s with the Balanced Budget Act. The first RADV audit for MAOs wasn't performed until 2007. The initial audits determined that MAOs were being significantly overpaid whic...

    • 13 min

Customer Reviews

5.0 out of 5
10 Ratings

10 Ratings

K. S. Wilson ,

Good source of information

Highly recommend for anyone working in the healthcare ecosystem, especially the payer sector.

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