CATEGORY: health-insurance

With restricted margins and changing bargaining relationships as providers consolidate and evolve, health insurers are looking more than ever to coordination of benefits to improve their bottom lines. Fortunately, modern digital tools powered by big data analytics, artificial intelligence and machine learning have revolutionized COB for insurers by putting the patient, instead of the claim, at[…]

When it comes to IT, health plans face a quality problem. In fact, it’s less that they face one problem and more that virtually their entire business model generates challenges for the strategy, governance and operation of high-quality IT infrastructures. Getting it right requires expertise and effort that few other industries demand.

Health plans make large investments to automate outdated processes when it comes to claims payment integrity expecting significant savings. Unfortunately, with this approach the expected savings don’t always materialize.

Health insurance policy changes at the federal level have captured the headlines in recent years, but in the long run some of the most profound changes to the industry have happened behind the scenes. The application of artificial intelligence and machine learning have impacted some of the industry’s most important practices.

While the basic challenges to health insurance payment integrity remain largely the same – ensuring responsibility for the claim, the eligibility of the consumer, the coverage under the contract, the validity of the claim and the lack of fraud, waste and abuse – the range of factors that bear on those challenges has expanded over time. Fortunately, so have the capabilities of insurers to deal[…]