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Category: Articles

  • Judge's gavel on a table with two business women working in the background

    Texas Medical Association Challenges Provisions to IDR Process

    On Thursday, September 22, the Texas Medical Association (TMA) filed a lawsuit challenging the August 19th Final Rule of the “Requirements Related to Surprise Billing.” The suit challenges provisions concerning the way Independent Dispute Resolution (IDR) entities must treat the Qualifying Payment Amount (QPA) compared to the additional factors described in the law: training/experience/outcomes; provider and plan market share; patient acuity; teaching status/case mix/scope of services of the facility; and prior good faith efforts to contract.

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  • Man looking confused

    Midyear Check-In with Healthcare Payors on the No Surprises Act

    Healthcare payors who believed they were prepared to comply with the No Surprises Act (NSA) without assistance have realized the new law is more complex than they initially thought. That’s the message Claritev has repeatedly received from clients who elected to try to manage the NSA or parts of it on their own.

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  • PHCS and NCQA logos with stethoscope

    MultiPlan’s PHCS Network Receives Eleventh Consecutive NCQA Accreditation in Credentialing

    In 2022, MultiPlan’s PHCS Network, the largest primary PPO in the nation, received its 11th consecutive Accreditation in Credentialing from the National Committee for Quality Assurance (NCQA), a private nonprofit organization dedicated to improving health care quality. The PHCS Network is the only national independently contracted primary PPO with NCQA accreditation, demonstrating its unique commitment to the accurate and efficient credentialing of health care professionals.

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  • Healthcare payors and providers collaboration

    Collaboration is No Longer Optional for Healthcare Players

    Healthcare costs in the U.S. are rising to $4 trillion annually, accounting for 17% of the economy. The increased pace towards a value-based care system could be a crucial step to rein in the rising cost of healthcare. This trend accelerates the need for collaboration between payors, providers, employers and health plan members.

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  • long road

    The Road to MRFs’ Final Data Schema Has Several Speedbumps

    In October 2020, CMS issued the Transparency in Coverage final rule. As part of this rule, health plans are required to publish machine-readable files (MRFs) for their negotiated rates, out-of-network allowed amounts, and prescription (Rx) coverage rates and allowed amounts. On March 1, 2022 approximately 18 months after the rule was issued, CMS locked v1.0.1 of the schema for MRFs. Getting to this “enforcement data schema” wasn’t easy. There were 20 other versions of the schema before it — and CMS may not be finished fine tuning it either.

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  • Man sitting on stairs while rubbing his hurt back

    What Is Subrogation?

    Subrogation? What is it and what does it have to do with healthcare insurance? Subrogation, in layman’s terms, means a health plan can be reimbursed by the party whose insured was deemed responsible for an accident or injury.

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  • Gold floating question mark on a pile of gray question marks

    Six Common Questions About Reference-Based Pricing Answered

    The beginning of the COVID-19 pandemic in 2020 gave rise to a new way in which payors, providers, employers, and employees look at healthcare. New questions emerged regarding the affordability of provider services, equality of access to healthcare services, and the overall model of how employers can offset organizational healthcare costs while ensuring affordable healthcare for their employees.

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  • Machine Learning to Maximize Workforce Efficiency

    Infographic: Maximizing Workforce Efficiency with Machine Learning

    This infographic demonstrates how Claritev used machine learning to maximize workforce efficiency with its negotiation prioritization tool. Claims negotiation is a time-consuming, high-touch process. Claritev embraced machine learning, combined with human intelligence to prioritize the workstream. Results? A near flawless implementation showed increased productivity and efficiency, greater customer value, and an award-winning tool—receiving the CIO 100 Award and the “Healthcare Data Solution of the Year” by Data Breakthrough.

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