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Risk Adjustment Services for MA Plans
Medicare Advantage (MA) plans face challenges in accurately assessing and managing member health risks, especially as regulations and CMS guidelines change. To ensure fair reimbursement and stay competitive, MA plans need strong risk adjustment strategies and precise documentation of Hierarchical Condition Categories (HCCs), since mistakes can lead to compliance issues and lost revenue. They also … Risk Adjustment Services for MA Plans
Advancing pharmacy management: The impact of biologics, biosimilars, GLP-1s, and data-driven insights
Healthcare costs continue to climb with the average per-person expense rising 6.7%—from $7,378 in 2024 to $7,871 in 2025. This increase is being driven primarily by two categories: pharmacy and outpatient facility care. Pharmacy costs alone grew by 9.7%, while outpatient facility care costs have risen by 8.5%. Collectively, these service areas are responsible for … Advancing pharmacy management: The impact of biologics, biosimilars, GLP-1s, and data-driven insights
Measuring how GLP-1 medications impact the total cost of care
Flexible analytics are valuable tools to inform the management of costs and outcomes for therapies such as glucagon-like peptide-1 (GLP-1) drugs, having a significant impact on payer spending and trend. This paper summarizes central themes and provides illustrative examples from Milliman’s GLP-1 Impact Dashboard suite of analytics to facilitate the strategic management of GLP-1-related care. … Measuring how GLP-1 medications impact the total cost of care
Expanding value-based care: The essential role of specialists in long-term success and patient outcomes
Value-based care (VBC) is reshaping the healthcare landscape by focusing on improving patient outcomes while keeping costs under control. Unlike fee-for-service (FFS) reimbursement, this approach prioritizes quality rather than quantity, aiming to reward effective treatments and preventative strategies that can lead to healthier communities and more sustainable healthcare spending. Traditionally, VBC initiatives have zeroed in … Expanding value-based care: The essential role of specialists in long-term success and patient outcomes
Navigating population health with clarity: Dr. Kodama’s expert tips for success in value-based healthcare
The shift toward value-based care (VBC) is transforming how services are delivered, focusing on improving patient outcomes and engagement while reducing costs. Success in this model depends on understanding your population, managing their health proactively, and coordinating care effectively. Meet Dr. Christopher Kodama, Chief Medical Officer at Milliman MedInsight. With a clinical background in pediatric … Navigating population health with clarity: Dr. Kodama’s expert tips for success in value-based healthcare
CMS 2025 RADV audit expansion: Key changes and what they mean to MA plans
In a significant move announced on May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) revealed plans to initiate annual Risk Adjustment Data Validation (RADV) audits for all Medicare Advantage (MA) plans. In this memo, CMS Administrator, Dr. Mehmet Oz, is quoted as saying “We are committed to crushing fraud, waste and abuse … CMS 2025 RADV audit expansion: Key changes and what they mean to MA plans
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Health system’s VBC analytics expert on the value of partnering with Milliman MedInsight
As SSM Health grew from a single state healthcare system to one that covers four states across the Midwest, its data needs grew proportionately. Darrin Dahl, SSM Health’s product owner for value-based care and finance, describes how the organization’s eight-year partnership with Milliman MedInsight has helped build the data infrastructure SSM needs to manage nearly … Health system’s VBC analytics expert on the value of partnering with Milliman MedInsight
Exploring low-value care use through an SDOH lens
Recognizing that low-value care is shaped by the broader healthcare environment and influenced by socioeconomic factors impacting care, Milliman MedInsight developed a model to explore the connections between low-value care and social determinants of health. The goal is to offer the healthcare industry actionable insights to enhance quality, efficiency, equity, and outcomes. In this blog … Exploring low-value care use through an SDOH lens
VBC contract modeling and management for profitability, efficiency, and better outcomes
Value-based care is a transformative approach with enormous potential for both improved patient outcomes and financial sustainability, but success requires a careful and complex alignment of incentives between payers and providers. For value-based care (VBC) to succeed, negotiations must begin with reliable performance metrics. Without a deep understanding of your financial performance, you cannot create … VBC contract modeling and management for profitability, efficiency, and better outcomes
The transformative impact of AI in healthcare analytics
Join us for an insightful webinar featuring industry experts as they explore the evolving role of Artificial Intelligence (AI) in reshaping healthcare analytics for payers and providers. This session builds on our February 2024 discussion, providing key updates on how AI continues to advance healthcare analytics and how Milliman MedInsight continues to integrate AI to … The transformative impact of AI in healthcare analytics
Challenges of childhood burden of cystic fibrosis
Cystic fibrosis (CF) is a genetic disorder that causes problems with breathing and digestion. CF affects about 35,000 people in the United States, with nearly half aged less than 18 years. Approximately half of the US patients with CF are covered by publicly funded programs for people with low incomes. In this study, we summarize … Challenges of childhood burden of cystic fibrosis
Independent Health: Next-generation employer group reporting
Key sections: Action Results Looking ahead Download the story From its roots in a University of Buffalo graduate school project to its unique preventive care model, Independent Health Inc. has always taken an innovative approach to its role as a provider of health plans to approximately 380,000 residents of western New York. With a mission … Independent Health: Next-generation employer group reporting
