Josh Pappas’ Post

Prior authorization is a hot topic for everyone involved in healthcare—from patients to plans to providers. All want to get the process right. A new article by my Sagility colleagues offers three ways that prior authorizations can change healthcare for the better. Read the article and let me know what you think! Thanks! https://lnkd.in/d7qiEKU5 #Healthcare #PriorAuthorization #Payer #Provider

As I reflect on 2024, there were a lot of developments in the healthcare sphere — many of which helped lower the barrier to Medicare and improved Medicare benefits. On a recent article by Becker’s Payer, five payer CEOS share their insights on the best strategy changes they made in 2024 — definitely an interesting read! #2024 #Healthcare #Strategy #CEO

With news everyday that health systems are withdrawing from Medicare Advantage (MA contracts), our team at the Healthcare Quality and Outcomes Lab has been studying the relationship between health systems and MA health plans. While health systems may be pulling out of MA contracts due to low reimbursement or administrative burden from claims denial, they may also be launching their own MA plans. In new research published in JAMA Health Forum, we identify that almost 1 in 7 Medicare Advantage beneficiaries are enrolled in MA plans offered by or affiliated with integrated health systems. On average these plans had favorable quality star ratings, but ongoing assessment is needed on the impact for patients. https://lnkd.in/eC8sd4dn

Health systems are grappling with burdensome authorization requirements and high denial rates from Medicare Advantage plans, prompting considerations of discontinuing participation.   According to the "HFMA Health System CFO Pain Points Study 2024," 16% of surveyed health systems plan to cease accepting one or more Medicare Advantage plans within two years, with 45% contemplating similar actions.   To address these challenges, our RCM team provides comprehensive solutions. We analyze authorization processes, identify bottlenecks, and streamline workflows to minimize denials.   Leveraging expertise in Medicare Advantage regulations, we assist health systems in optimizing revenue cycle management strategies. By offering tailored guidance and proactive support, we empower organizations to navigate complex payer landscapes effectively. Our goal is to ensure financial viability while maintaining high-quality care standards, enabling health systems to make informed decisions aligned with their long-term objectives.   We are the One!   #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Becker's Healthcare

In the News: As commercial payers saw record gains in recent years while many providers continued to face rising operational costs, labor shortages, and Medicare Advantage challenges, hospitals and health systems are taking a harder line in contract negotiations, according to a recent Becker's Healthcare article. Media reports of contract-negotiation disputes between payers and providers skyrocketed by 69% from 2022 to 2023. Early indicators suggest this contentious trend is intensifying in 2024. Dive deeper into the article here: https://hubs.li/Q02QhcYX0 #hospitalfinance #healthcarecosts #beckershealthcare #contractnegotiations #medicareadvantage #laborshortages #rcm #revenuecyclemanagement #revenuecyclestressors #operatingmargins #hospitalrevenuecycle #hospitalrevenue #hospitalmargins #patientoutcomes

Our latest blog post provides an analysis of the Patient Price Transparency topic that has become a hot topic in the healthcare industry. The post covers three ways to address this issue with patients and highlights key issues rural healthcare providers should be aware of. If you're interested in learning more about this important topic, check out our blog post here: https://lnkd.in/gGYqnVCb #PatientPriceTransparency #HealthCare #Rural #hospital #revenuecyclemanagement

Fiscal rationing of physician reimbursement by insurers augments prior authorization rationing of physician recommended care to enhance profits for health insurers with no evidence that this improves access, outcomes or costs for patients. The quantity or consequences of this rationing is never revealed or transparent. #tripleaim #medicareadvantage #healthcare #hmo #publicprivatepartnership

Johns Hopkins Health Plans recently revealed a new multi-payer portal designed to simplify healthcare administration for providers within their network. Powered by Availity Essentials, this secure platform offers real-time features to streamline communication and transactions between providers and payers. Benefits for Providers: - Providers can electronically submit and track claims, check claim status, and access remittance and payment information. - AI-powered features provide valuable insights into financial and administrative data, allowing for faster access to accurate information. - Future enhancements promise more timely access to member information through improved reports. - The portal aims to alleviate administrative burdens for providers, allowing them to focus on delivering quality care. Learn more: https://hubs.ly/Q02zQC900

Why does this strategy work? Because, ultimately, payers don't care. Employers want the broadest possible network and there seems to be no upper limit on premiums. If you have healthcare through your employer, YOU are paying the price. There is an alternative. It requires some compromise, but it exists. Message me if you want to discuss.

Traditional healthcare delivery has been disrupted, and health systems need to adjust their clinical models to stay competitive. At Guidehouse's 2024 Medicare Advantage Summit, healthcare leaders discussed how to meet the changing needs and wants of consumers. Learn from panelists Michael Flammini (Privia Health), Chris Stanley, MD (Populance), and Benjamin Zaniello, MD MPH (Best Buy Health). #clinicalmodels #healthcaredelivery