As Product Line Manager, it’s my job to try different approaches for gathering better feedback from our users. That’s why, when I was first tasked with redesigning Availity’s Remittance Viewer tool, I started with a customer advisory board. This insider channel helped me elicit raw feedback from my target audience. Additionally, daily reports and in-person provider usability studies have helped increase my understanding of our users’ pain points. The result is a redesigned, shiny new Remittance Viewer Tool.

1,270 miles and 25 hours— That is the mileage and travel time Genevieve “GG” Nabritt spent per week commuting back and forth from her home in Dunnellon, Florida to Jacksonville to work as a customer service representative three and a half years ago.

The father-daughter duo both play important roles in their respective departments. Fred is a 19-year veteran and the Director of Strategic Alliances for HCSC, one of Availity’s owner health plans. Availity was the first company to help Christine to “get her foot in the door” as a Client Services Representative after graduating UF in 2014 with a degree in Marketing.

Chelsea graduated from Florida State University with a degree in Business Marketing. After graduating, she landed a job as a health IT recruiter for a consulting company in Jacksonville and Availity was one of her clients. Working closely with Availity, Chelsea soon accepted an offer for a full-time Senior Staffing Consultant position.

Availity helps healthcare providers and health plans connect, making it easier to share clinical, financial, and administrative information. We value your business and respect the security of your patient data, which is why we’re introducing additional authentication measures.

We may never completely eliminate denials, but there are ways to proactively prevent them, particularly recurring denials caused by your claim workflow. From small practices to large Epic health systems, we see a surge in customers working to dramatically reduce error rates, improve cash flow, and reduce write-offs.

Even in the most technology-savvy provider offices, there may be lingering paper-based manual processes eating away at your bottom line. Perhaps you work with a payer that only accepts paper forms for secondary or Worker’s Comp claims. Or maybe your business requires regular printing and faxing of documentation to support your electronic claims.

Countless businesses and healthcare organizations miss out on their portion of available settlement proceeds each year. On average, only about 20% of eligible entities collect their share of any given settlement fund. In many cases, the proceeds represent a significant amount that is added right to your bottom line. While settlements vary, one constant is that a claim must be submitted in order to collect any money. This is where a Settlement Recovery Service can help.

In a recent webinar, we discussed the importance of patient satisfaction and how it can impact the revenue of your practice. Understanding patient satisfaction is valuable for providers who want their patients to keep coming back. Here’s how practitioners can keep retention high and ultimately grow their practice.

In a recent webinar TSYS coordinated with Availity, we discussed the importance of understanding today’s patients and their unique expectations. This understanding is measured by patient satisfaction, which gives providers valuable insights into the effectiveness of their care. Increasing patient satisfaction has become a major initiative for practitioners because it’s directly linked to patient retention. Here are the 5 components of improving patient satisfaction at your dental practice.

A key to patient engagement is keeping your clients as informed as possible about their options for treatment, medications, recovery, and all other aspects of the healthcare system. A practice that is fully engaged with their patients works more efficiently, from setting up follow-up visits to receiving electronic reminders about appointments, and this personalized engagement is now expected. Digital communication is not something you can disregard—patients want personalization and the ability to speak to their health practitioner on the platforms they us

There’s a fun phrase about dental practices: “When the front office hums, the back-office dances.” How does the front office hum? Let me paint you the picture—the front office staff is answering phones, greeting patients who walk in, and working their daily schedule.

“Inform before you perform.” Does your office have a written financial policy? If not, you should. This policy should be presented to and signed by all patients, especially at the time of their first appointment. This sets the ground rules. Keep a copy of the signed document in their patient records. Your financial policy should include all payment options and treatment should not commence until the payment arrangements are settled. A successful policy is one that is clearly presented and consistently enforced.

The General Data Protection Regulation (GDPR) governs the privacy and security of personal data collected from the European market, effective May, 2018. Outside of the European Union (EU) and the European Economic Area (EEA), it only applies to those processing personal data of EU/EEA subjects for the purposes of offering goods or services or monitoring subjects’ behavior in the EU/EEA, but the law has had a major impact worldwide. While the primary objective of GDPR is to increase the protection and privacy of individuals’ data, it has produced a host of unintended privacy consequences, including its effect on ICANN and the WHOIS database.

Consumers with health insurance, both independent and employer sponsored, rely on insurers’ provider directories to make choices about their plans and find physicians that are right for them. Directories include vital information such as essential contact details, distance from public transportation, accessibility for individuals with disabilities, languages spoken by practitioners and staff members, and more.

The healthcare industry still has a big paper problem. According to one report, faxes account for almost 75 percent of all medical communication.

Health plans are committed to reducing waste and inefficiency, but the healthcare industry as a whole still spends too much time and money manually managing administrative transactions. One report found that faxes account for almost 75 percent of all medical communication, and the 2017 CAQH report predicted administrative costs would reach $315 billion by the end of the year. These costs are driven largely by the continued reliance on phone calls, fax, and mail to manage claims transactions.

Claim submissions are the most common electronic transactions in healthcare, edging out even eligibility and benefits checks, which are often still performed by phone. It’s clear that submitting claims electronically leads to faster payments and fewer denials, at less cost to providers and payers, however six percent of claims are still submitted via paper.

Countless businesses and healthcare organizations miss out on their portion of available settlement proceeds each year. On average, only about 20% of eligible entities collect their share of any given settlement fund. In many cases, the proceeds represent a significant amount that is added right to your bottom line. While settlements vary, one constant is that a claim must be submitted in order to collect any money. This is where a Settlement Recovery Service can help.

CMS’s recent report on the state of provider directories identified three challenges facing health plans. Recent blogs covered the first two challenges: the issue of contractual versus resource constraints and the lack of internal audits by health plans to verify provider information. A third problem creating directory inaccuracies is that health plans rely on providers to reach out and tell them when information changes. From the report: “MAOs cannot assume that they will be informed when a change in provider location occurs; instead, MAOs need to implement routine processes that drive more accurate information reflected in their directories.”

The second problem CMS identified in its report on provider directories was a lack of internal audits by health plans to verify provider information. The report faulted health plans for outsourcing the audit process, stating “Medicare Advantage Organizations (MAOs) placed full faith in credentialing services and vendor support, and even in provider responses...” and “if MAOs had implemented routine oversight of their processes for data validation, errors in the provider directory would have become apparent.”

The RISE conference in Nashville was a great opportunity to learn about new approaches to analytics and member engagement, as well as to hear about many of the creative initiatives health plans are implementing to improve quality scores and meet the complex web of risk adjustment requirements for Medicare Advantage, ACA, and Medicaid.

What’s the current state of payer-provider collaboration, and what does the future hold? Big questions to be sure, but we tried to find answers during a recent Availity-sponsored SmartBrief webinar featuring healthcare industry expert Jay Eisenstock of JE Consulting.

CMS has identified three drivers of directory deficiencies: group vs. provider-level data, lack of internal audits, and reliance on provider-led notifications. We've outlined these issues in an infographic.

In its second annual report on the state of provider directories, the Centers for Medicare and Medicaid Services (CMS) found that 46 percent of all directory entries reviewed contained at least one error that makes it difficult for patients to find doctors in their networks.

Recently, three trends have aligned to signal highly favorable conditions in the independent radiology space for the coming year. These trends are: (i) a resurgence of the patient steerage debate; (ii) an increase in patient consumerism; and (iii) advances in pre-service technology that could significantly improve practice efficiency. Independent radiology centers that take steps now to prepare will be in an enviable position next year and better able to capitalize on these trends.

Your health plan has enough claims to process without adding ones that don’t belong to your organization. But that’s what happens when claims with invalid member or provider IDs enter your adjudication system. Internal resources can spend significant time working these before the error is discovered, which means higher staffing and administrative costs.

Availity understands that if you want to drive provider engagement, you need to find new ways to automate healthcare transactions. That’s why we are introducing two new automated workflows within our Provider Engagement Portal: appeals and overpayments.

Join us Friday, 11/10 at 1pm ET for our tweetchat, Confidence Through Compliance, featuring our favorite HIPAA lawyer, Matt Fisher (@Matt_R_Fisher), and our Availity compliance guru, Erika Ables (@Erika_Ethics), as we discuss how compliance can enhance everything in healthcare from cybersecurity to patient interactions.

In this edition of Availity Access, Mark Martin, product line director for provider data, discusses why addressing credentialing is the next logical step in Availity’s work to simplify data verification and improve the quality of provider data throughout the health care data ecosystem.

Working in healthcare guarantees you’ll be interrupted multiple times a day, whether it’s by staff, patients, physicians, or health plans. Fortunately, there are some tasks that can be completed on your timeline. Even better, when you get ahead of them you can greatly reduce the number of interruptions you face.

Availity recently commissioned an independent research company to survey providers—physicians and non-medical staff, in practices and facilities—about their credentialing process. No one should be surprised that providers are not happy with how it’s conducted.

“If you see this text, then your files are no longer accessible because they have been encrypted.” This is the on-screen message many organizations and individuals saw Tuesday, June 27 when a massive cyber-attack froze thousands of computers, especially in Ukraine, Russia, and the U.S. The message went on to demand $300 in Bitcoin as ransom, promising to employ a decryption service upon payment. The attack, originating in Ukraine, affected a number of large companies—and at least one U.S. hospital—resulting in millions of dollars in lost revenue and disruption.

Join us Friday, 10/13 at 1pm ET for our tweetchat, Healthcare Credentialing: The Good, the Bad, and the Scary, featuring Michelle Barry, our expert of health plan provider data management, Don Lee, president of Glide Health IT, and Shahid Shah, The Healthcare IT Guy, as we discuss what processes and tech can remove the dread that looms around healthcare credentialing.

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) was passed to make healthcare delivery more efficient and to protect the privacy of patients. In general, HIPAA does not distinguish between physical and mental health in protecting patient privacy. While some advocates argue that not distinguishing between physical and mental health is the only way to protect the privacy of those with mental illnesses, others, including many families with loved ones suffering from mental illness, argue that excluding family members from mental health records can have a devastating effect on the patient, the family, and the public.

Recognizing the need for greater automation, the CAQH Committee on Operating Rules for Information Exchange® (CAQH CORE®) brought entities from across government and the industry together to develop healthcare operating rules for electronic business transactions.

Supporting our communities has always been a part of Availity’s corporate culture. By providing a variety of opportunities to give—and by making it easy to participate—Availity cultivates this giving culture among all our employees across multiple locations.

In our latest vlog series, Mohammed Ahmed, Availity’s Vice President of Authorizations Sales Enablement, provides insight into the key features and functions you should look for in an automated authorization solution.

Join us Friday, 9/8 at 1pm ET for our tweetchat, Big Data - Present, Future, and Best Practices, featuring Availity Director of Data Management and Analytics, Jeff Currier (@_jcurrier_), as we discuss how healthcare can and IS using Big Data to improve everything from costs to patient experience.

In our latest vlog series, Mohammed Ahmed, Availity’s Vice President of Authorizations Sales Enablement, provides insight into the key features and functions you should look for in an automated authorization solution.

In our latest vlog series, Mohammed Ahmed, Availity’s Vice President of Authorizations Sales Enablement, provides insight into the key features and functions you should look for in an automated authorization solution.

Join us Friday, 8/11 at 1pm ET for our tweetchat, Patient as the New Payer – Patient Payments, featuring TSYS’s Director of Relationship Management, Ben Buchanan (@benbuchanan28), and our own Principal of Payment Solutions, Sean Kilpatrick (@spkilpatrick), as we discuss the why and how of assessing, capturing, and collecting patient payments in our new healthcare world.

On this journey to value-based care, providers and health plans agree that collaboration is critical to their success. But significant investments in proprietary IT systems over time—for payers and providers—have resulted in highly fragmented systems that stifle collaboration and drive up administrative costs.

Two things health plans and providers can agree on are the importance of improving patient satisfaction and lowering administrative costs. They also know that increased communication and collaboration are necessary to achieve these goals. The challenge is that neither health plans nor providers have made improving communication a business priority.

Join us Friday, 7/14 at 1pm ET for our tweetchat, The (Continued) Case for Interoperability, featuring our own Platform Solutions Architect, David Quickstad (@DQuickstad), and the CTO of HL7, Wayne Kubick (@WayneKubick), as we discuss how interoperability has become increasingly important in healthcare.

Understanding the needs of customers is paramount to any business’s success. And for Availity, a long-time, trusted intermediary between health plans and providers, understanding and appeasing both segments of the healthcare market has its challenges. Despite the development of integrated digital tools and improved processes and workflows, the relationship between these healthcare stakeholders is historically influenced by friction—even though both recognize a need to work together.

Elizabeth Woodcock, a leading expert on medical practice operations, is on a mission to help the healthcare industry improve the patient experience. In conjunction with the Availity Learning Center, she created a new on-demand training series, The Patient Relations Superstar, which launches this month.

If you’re a healthcare provider still processing most claims manually, you know first-hand the challenges this presents. First, you deal with a lot of paper—from spreadsheets to claims forms to sticky notes— just to keep track of what you billed, what got paid, and what got denied. Second, you spend a lot of time communicating with the payers to track down claims, follow up on payments, and reissue remittances. Automating these processes sounds good, but what kind of results can you really expect?

Is your revenue at risk? If your hospital or practice isn’t fully adhering to the risk adjustment and Hierarchical Condition Category (HCC) coding requirements for Medicare Advantage (and some Medicaid) plans, the answer may be yes. Many healthcare organizations underestimate what’s required for these plans and it’s costing them money.

A recent report by CAQH demonstrated that outdated, time-consuming manual processes are still being utilized to exchange information between insurers and providers, particularly financial and administrative data, and it costs us all a fortune. What can we do about this waste? CAQH CORE is a non-profit that brings entities across the healthcare industry together to encourage automation by promoting a common set of rules and underlying standards governing electronic data exchange. To highlight which entities are meeting – or exceeding – these rules and standards, CAQH CORE has developed a certification program.

Join us Friday, 4/14 at 1pm ET for our Assessing Quality Measures tweetchat featuring our own Risk Queen, Susan Bellile (@SKB_RnQ), and The Healthcare IT Guy, Shahid Shah (@ShahidNShah), as we discuss the current and future role of quality measures through technology, legislation, and innovation.

“How well does this vendor integrate with Epic?” It’s an increasingly important question among hospitals and health systems that run Epic and are considering a new claims and clearinghouse solution. It was one of the questions Community Health Network—a non-profit health system with more than 200 sites of care throughout Central Indiana—asked as it sought to consolidate the number of revenue cycle solutions in use across the organization.

Any successful company recognizes the importance of customer touchpoints—those critical moments when a customer engages with someone in the organization. “With the rise of consumerism, healthcare organizations are no different,” says Sarah Holt, a nationally known author and healthcare management consultant. Holt believes that for too long hospitals and physician practices haven’t focused enough on business operations, assuming clinical expertise would make up for any shortcomings.

Last year, Availity, the nation’s largest real-time health information network, participated in a pilot initiative with America's Health Insurance Plans (AHIP) to identify solutions for providing real-time updates and validation of provider directories through a single workflow. See the results!

Join us Friday, 3/10 at 1pm ET for our Ransomware Predictions and Prevention tweetchat featuring Matt Fisher (@Matt_R_Fisher) and Erik Azar (@eazar), where we’ll talk about how ransomware affects healthcare now, how to prevent a #ransomware attack, and what the future of #cybersecurity might hold for #healthcare.

Because patients are paying more out of pocket for their healthcare, you might be focusing on improving patient collection processes. While that’s critical, it’s also important not to lose sight of the other side of the revenue equation—the payer. Elizabeth Woodcock, MBA, FACMPE, CPC, an expert on medical practice operations and revenue cycle management, shares her thoughts on how to approach denials in your organization.

With all the uncertainty, there’s one question that keeps surfacing—will risk adjustment go away if Congress repeals the Affordable Care Act (ACA)? The answer is no and here’s why – risk-based financial models extend far beyond those included in the ACA.

As part of a partnership with the Illinois Critical Access Hospital (ICAHN), Availity is working with several hospitals across the state to streamline registration operations and improve patient collections. By implementing our Patient Access solution, several have seen significant improvements, which have helped them maintain financial viability in a changing healthcare marketplace. In a newly published case study, we look at the challenges these hospitals face and the success they’ve had to date.

In this episode of Availity Access, Jeff Chester, Availity’s Chief Revenue Officer and Senior Vice President, discusses what he sees as the big healthcare trends in 2017.

Nationwide, just over six percent of healthcare claims are submitted using paper forms. That number has remained steady over the past few years, even though research has shown conclusively that providers can save more than 50 percent on administrative costs by submitting claims electronically.

Whether you’re new to healthcare or a seasoned veteran, understanding the revenue cycle is tough—not to mention staying up-to-date with myriad legislative and policy changes that can impact your revenue cycle over time.

As 2016 comes to a close, you are probably wrapping up a few last projects and making your holiday vacation plans. Before you scoot off to grandma’s house or strap on the skis for a downhill adventure, make sure your budget is in order. And if you have dollars left to spend, spend them wisely. A “wise” purchase to consider is healthcare training courses for you and your staff. Not only will you maximize your annual budget, but it’s a good opportunity for your employees to sharpen their skills during this slower time of year.

We know what you want for the holidays – Risk Adjustment! That’s why we’re hosting our third #AskAvaility tweetchat on Friday, 12/9 at 1pm ET, discussing All Things Risk Adjustment. Availity’s Susan Bellile (@SKB_RnQ) joins Steve Sisko (@ShimCode) to talk about the current and future impact of Risk Adjustment on healthcare.

A business continuity plan is a dynamic tool used during emergencies, catastrophic events and natural disasters where buildings, personnel, and technology may be impacted. A well-designed business continuity plan documents what processes need to be in place to ensure your organization is able to quickly resume normal business functions in the event of a disaster.

We’re back at it again with another #AskAvaility tweetchat! Join us on Friday, 11/11 at 1pm EST for Exploring APIs in Healthcare. Steve Sisko (@ShimCode) is returning to our chat joined by Dr. Charles Webster (@wareFLO) and our own Steve Vaughn (@RealSteveVaughn) to discuss the ins, outs, ups, downs, pros, cons, and everything in between regarding APIs in healthcare.

With more patients enrolled in high-deductible health plans, front-desk employees are facing difficult questions from patients about their healthcare coverage, but many lack the skills and training necessary to answer them. Here are 3 steps to help patient access staff provide better answers to difficult questions.

A recent Availity survey of providers found that almost half still mail or fax their risk assessments to payers. Results suggest this is because each payer has a different way to submit paperwork and most lack digital submission tools. In fact, almost 75 percent of survey respondents cited minimal standardization as their biggest pain point.

Come join @ShimCode and @HIT_MMartin to talk about the communications (or lack thereof) between providers and payers and the ways in which we can increase communications and data sharing between these two entities.

In this episode of Availity Access we discuss the problems caused when payers and providers each build their own solutions to manage patient data.

Cyber threats represent a big risk to healthcare practices but keeping your staff up-to-date on HIPAA training will send the message that this topic is mission-critical to your practice.

In this episode of Availity Access we discuss solutions that can streamline data sharing processes and reduce manual workflows for payers and providers.

In this episode of Availity Access we discuss how automation has affected the claims submission and processing activities for payers and providers.

The landscape of social media is fast-changing and the law is sometimes one step behind. Here are 4 ways your hospital or medical practice can take to guard against disclosure of patient information on social media.

Availity Access provides a glimpse into the people behind our products. It features commentary on challenges facing the healthcare industry and how Availity can help providers and health plans better share patient information. In this episode we discuss big data and the challenges it presents for risk adjustment.

Risk adjustment is used to calculate the underlying health status of a health plan’s population. For Medicare Advantage, it is the most significant factor in determining a health plan’s reimbursement. For exchange plans established under the Affordable Care Act (ACA), it determines whether the plan will receive additional funds or be asked to pay additional money at the end of the year.

The Care Cost Estimator is another example of how healthcare organizations are using APIs to facilitate communication between health plans and providers—without having to develop custom solutions. Not only do APIs reduce development time and costs, but they helps plans deliver more accurate estimates to providers and their patients.

MACRA offers multiple pathways with varying levels of risk and reward for providers to tie more of their Medicare payments to value. It’s important for providers to demonstrate value because they’re rewarded for giving better care not just more care.

It seems like every day there’s a different news story about millennials. What they buy. How they communicate. How to work with them. Not since their parents—the baby boomers—came of age have we seen this level of media interest in a generation.

Availity Access gives viewers a glimpse into the people behind our products. It features commentary on challenges facing the healthcare industry and how Availity can help providers and health plans better share patient information. In this first episode, we discuss why the risk adjustment process is difficult for health plans and how digital tools can help streamline it.

Health plans are increasingly under pressure to maintain accurate provider directories, or they risk regulatory fines and potential third-party lawsuits. Given these regulatory and market pressures, healthcare providers are likely to see a lot more requests for up-to-date demographic data from your partner health plans.

Following the horrific June 12, 2016, shooting at the Pulse night club in Orlando, Florida, news outlets across the country rushed to report on the events of that night and the aftermath of the tragic situation. While covering breaking news is inherently an imperfect science, multiple news agencies threw caution to the wind and erroneously reported that the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) regulations were waived following the massacre to allow family members easier access to their loved ones’ health information.

It is not an overstatement to say the healthcare industry has experienced unprecedented change since the Affordable Care Act (ACA) was passed in 2010. Healthcare has fundamentally evolved in how it is delivered and how payers are reimbursed for the care they give patients.

“Sudden” changes in the information we have and how we use it are usually not all that sudden, and it’s almost impossible to predict their effects. Whether it’s pinpoint accuracy in location data or efficient sharing of health care information, improved technology, changing attitudes about the technology, and government pressure often lead to unexpected consequences.

The American Recovery and Reinvestment Act of 2009 created an electronic health record (“EHR”) incentive program, commonly referred to as “Meaningful Use.” The program pays incentives to certain providers and hospitals to implement and make meaningful use of certified EHR technology. The three main components of Meaningful Use include: (1) the use of certified EHR technology in a “meaningful” manner; (2) the electronic exchange of health care information to improve the quality of care patients receive; and (3) the use of certified EHR technology to submit clinical quality and other measures.

As long as there’s been medical insurance claims there’s been a tug-of-war between payers and providers. Payers want clean claims and providers want to get paid promptly. Meanwhile, “dirty claims” — those with errors — are causing billions of dollars in added expenses for the healthcare industry because payers and providers have to retain extra resources to manage the rework and manual processes, among other factors. Experts agree that both payers and providers are at fault for the “calamity of claims” that exists today.

Providers submit millions of claims to payers every day. Most are adjudicated promptly and for the full contracted amount, but a fraction of these claims are denied. However, the American Medical Association (AMA) reports that between 1.38% and 5.07% of claims are denied by payers on first submission.

In two recent blog posts, we talked about the promise “Big Data” holds for risk adjustment and some of the challenges health plans face with existing systems and processes. In the final blog of this series, we look at how the Member Assessment application, part of Availity’s Revenue Program Management (RPM) solution, helped one large health plan improve the risk adjustment process.

Payers need information about the population of members in their health plans to predict and track healthcare costs, and to comply with regulatory requirements for risk adjustment and quality assessment. The latter is particularly important for members in Medicare Advantage, Medicaid managed care and Affordable Care

The administrative employees of critical access hospitals typically wear many hats. With extremely tight margins and few alternative funding sources, smaller institutions must keep staffing at a minimum to effectively manage cash flow. So, it’s not surprising when the person who checks patients in at the registration desk is the same person who handles administrative responsibilities for the emergency department.

Healthcare providers are in the middle of enormous change. Declining reimbursement, the transition from fee-for-service to value-based payment models, and consumerism are all influencing the way providers get paid, how much they get paid—even whether they get paid at all. While it’s difficult to stop in the middle of managing these changes to evaluate existing revenue cycle processes, it’s an important step in ensuring your organization is positioned for success.

In a recent blog post, Can “Big Data” help address the challenges of risk adjustment,” we looked at why risk adjustment is critical to the successful implementation of value-based payment models. But risk adjustment models rely on timely and accurate provider data, and many health plans don’t have the systems and processes in place to efficiently capture the right data points, relying instead on manual, labor-intensive processes. As a result, health plans face the following challenges related to organizational efficiency and provider network satisfaction.

When open enrollment begins for Qualified Health Plans (QHP) offered through a Marketplace in 2017, eligible individuals and families will—for the first time—have access to health plan quality ratings. The Affordable Care Act (ACA) “Quality Rating System” (QRS) star ratings will be published on each QHP issuer’s website as well as HealthCare.gov.

Much has been written about “Big Data” and its potential for helping companies turn information it collects into critical business insights. Amazon’s product recommendation feature is one example of big data at work, but companies are also using it as a tool for many strategic decisions, including pricing, staffing, and product development. As the health care industry transitions from fee-based to value-based care models, big data holds a lot of promise for health plans and providers who are looking for better ways to measure value and assess risk within patient populations. One important area is risk adjustment.

As the healthcare industry transitions to value-based models of care and reimbursement, providers and payers need to engage with one another to align and improve outcomes related to quality, cost, and administrative efficiencies. Creating a successful payer-provider relationship depends on both parties coming to the table with an open mind and a commitment to establishing and maintaining trust. With this foundation in place, they can focus on creating alignment in several key areas.

Healthcare providers know all too well how consumerism is affecting their bottom line. As high-deductible plans become more common and patients are responsible for a larger portion of their healthcare costs, hospitals and physician practices are finding it more difficult to collect the full portion of the patient responsibility.

Based on feedback from recent healthcare events, including last fall’s Health 2.0 and this month’s J.P. Morgan Healthcare Conference, many expect 2016 to be a year of significant technology advancements. Whether it’s developing personalized medicine applications, executing on value-based payment initiatives, or addressing the challenges of consumerism, healthcare companies are focusing on innovation.

In a previous blog, “Learn How a Settlement Recovery Service Can Help You and Your Organization”, we introduced several types of settlements. One of the types mentioned was a “product anti-competition” settlement, which relates to products with allegedly inflated prices that were purchased either directly or indirectly from certain companies. The Polyurethane Foam Antitrust Litigation Class Action Settlement, also known as the Poly Foam Settlement, is an example of this type of settlement. At $151 million, the settlement fund is both substantial and rare, and organizations potentially affected by alleged overpayments may want to consider filing a claim.

The Affordable Care Act (ACA) requires health insurance companies to spend a minimum amount of premiums collected from members on specific categories of activities that are intended to benefit those members. This is known as the Medical Loss Ratio (MLR). Each year, health plans are required to report their MLR for the preceding year; in the event they do not meet the mandated ratio, those health plans must issue rebates to their customers. The MLR requirement is intended to provide greater transparency and accountability around the expenditures made by health insurers and to help bring down the costs of health care.

Few healthcare technology implementations are as expensive, complex, and involve as many stakeholders as an electronic health record (EHR). Many hospitals and health systems naturally focus on the clinical functionality of a new EHR system, placing revenue cycle management (RCM) lower on the list of priorities.