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Becker’s Payer Issues Roundtable Recap: Key insights for health plan leaders
At this year’s Becker’s Payer Issues Roundtable, one message came through consistently: the challenge for payer organizations isn’t new ideas. They need execution that measurably bends trend while keeping decisions defensible in a more scrutinized environment. Across markets, leaders described a world of tighter margins, higher acuity, member disruption, and growing expectations that plans will … Becker’s Payer Issues Roundtable Recap: Key insights for health plan leaders
From readiness to reality: What TEAM’s first year is really testing
In January 2026, CMS’s Transforming Episode Accountability Model (TEAM) moved from policy to practice. For hospitals in mandatory regions, TEAM is no longer something to prepare for on paper; it is live, operational, and beginning to influence how episode performance is evaluated clinically, financially, and operationally. Many organizations are entering 2026 with a measured posture. … From readiness to reality: What TEAM’s first year is really testing
Medicare Advantage 2026: Breaking down the new risk model and its impact in plain terms
The Centers for Medicare & Medicaid Services (CMS) introduced CMS-HCC Version 28 (V28) in 2024 as the next evolution of Medicare Advantage (MA) risk adjustment. For many organizations, the “new CMS-HCC model” felt more theoretical than operational, something plans were preparing for but not fully experiencing. That changes in 2026, when V28 becomes operational at … Medicare Advantage 2026: Breaking down the new risk model and its impact in plain terms
How CareFirst BlueCross BlueShield modernized analytics to cut cost of care
Health plans are walking a tightrope. On one side, utilization is climbing and breakthrough therapies, while clinically promising, are reshaping cost curves. On the other hand, members, employers, and providers expect more convenience, transparency, and value. The mandate is clear: deliver better outcomes and experiences without sacrificing affordability. Meeting that mandate requires more than more … How CareFirst BlueCross BlueShield modernized analytics to cut cost of care
Physician performance enablement: Engaging providers with actionable insights for ACO success
Many organizations now have access to more data than ever before, yet they often struggle to transform this information into practical actions that lead to real improvements in population health. Physicians play a vital role in this process and should be involved early when turning data into meaningful insights that are practical, effective, and aligned … Physician performance enablement: Engaging providers with actionable insights for ACO success
HIMSS26: From data foundations to operational execution in healthcare AI
The HIMSS Global Health Conference and Exhibition has long served as a signal for where healthcare technology is headed. This year’s conference, attended by more than 24,000 healthcare leaders, reflected an industry that has moved past curiosity and into a more demanding phase of transformation. Artificial intelligence (AI), interoperability, and digital infrastructure remained central topics … HIMSS26: From data foundations to operational execution in healthcare AI
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Health Data Analytics for Identifying Wasteful Services
Eliminating inefficient and unnecessary medical services improves overall healthcare efficiency while reducing costs. In 2009, the Institute of Medicine (IOM) identified $750 billion of wasted spending, with unnecessary services accounting for $210 billion. The Congressional Budget Office has estimated that 30% of medical care in the U.S. is unnecessary care. (Source: Institute of Medicine article … Health Data Analytics for Identifying Wasteful Services
Utilization Health Waste in the US Healthcare Marketplace
The American Healthcare system is experiencing rapid change, largely driven by the recognition by both public and private payers that the trajectory of healthcare spending growth must be slowed. Despite the recent slowdown in healthcare spending growth, which many attribute to the recession, efforts to transform benefit design and payment systems are proceeding rapidly. For … Utilization Health Waste in the US Healthcare Marketplace
Site of Service Savings Opportunities
Most people working in healthcare know that the cost for the same service can vary significantly by setting (e.g. office based vs hospital) and by provider within a setting. The example below illustrates this for a simple surgery with the price doubling in the Ambulatory Surgery Center (ASC) setting and being almost 5 times as … Site of Service Savings Opportunities
Analytic Basics – Completeness and Outlier Episode Flags
Analysts working with episode of care groupers for the first time often have questions about how to use the various value-added flags assigned to episodes. Episode of care groupers link together all of the claims that pertain to the treatment of a particular condition for a particular patient, to create a powerful unit of analysis. … Analytic Basics – Completeness and Outlier Episode Flags
Do Not Overlook the Value of Claims Auditing
This article was originally published in Employee Benefit News. It was written by both David Cusick and Brian Anderson. When seeking ways to keep expenses under control, health care plan sponsors may overlook the value of claims auditing. Auditing fees may not be inconsequential, but the fact is that an accurate audit including both pharmacy … Do Not Overlook the Value of Claims Auditing
Too Many Spinal Surgeries?
Hospitals have historically relied on surgeries contributing to their top service lines and providing a significant source of revenue generation for hospitals and surgeons. This has, in part, led to the overutilization of surgeries. In the area of spinal surgeries, as noted in the Modern Healthcare article from March 24, 2014, the mounting research evidence … Too Many Spinal Surgeries?
