Payer

The payer business model built for the last twenty years can’t carry the next ten. At Becker’s Spring Payer Issues Roundtable, the leaders running health plans at Humana, Kaiser Permanente, Blue Shield of California, Elevance Health, Highmark, Oscar Health and…

Consumer demand for virtual care continues to grow — and expectations are expanding beyond episodic care. New research shows insured adults are increasingly open to using virtual care across a broader range of needs, yet real‑world use has not fully…

Musculoskeletal conditions are among the largest cost drivers for Medicare Advantage plans. As populations age, surgical interventions and downstream utilization continue to drive spending — even when conservative care options may be appropriate. A new analysis of Medicare Advantage members…

Today’s Medicare Advantage payers are navigating rising enrollment, changing HCC models and heightened audit scrutiny from CMS. At the same time, quality standards continue to tighten, putting Star Ratings and revenue at risk when documentation and coding fall short. This…

Payer leaders are managing deeper downside risk, tighter margins and rising expectations for transparency, quality reporting and audit readiness. This guide outlines a practical framework for using AI in value-based care while managing compliance and operational risk. Rather than focusing…

Health plans are under pressure to improve member engagement while managing rising costs and increasing expectations around personalization. Medicare Advantage and Medicaid members are no longer passive recipients of benefits. They are consumers with clear preferences for flexibility, ease of…

2025 exposed hard truths: Denials surged. Trust collapsed. And affordability became the dominant barrier to care, not just on the Exchange and among the uninsured, but across Medicare Advantage and commercial plans alike. This 2026 outlook unpacks the forces reshaping…

Musculoskeletal spend is a top driver of healthcare costs—but it’s also one of the few areas where plan-year savings are realistic when AI-care is applied early. New research shows that when members begin MSK care through an AI-enabled, virtual-first care…

Medical loss ratios are crossing 90%, and traditional payment integrity models can’t keep up.  Teams waste months digging through vast amounts of unstructured documents, including CMS guidelines, reimbursement policies, contracts, and coding manuals, only to generate rules that never yield…

Payer-provider relationships have long been challenged by administrative complexity, inconsistent requirements and misaligned incentives. These issues can contribute to care delays, payment delays and unnecessary friction for both organizations. Inconsistent requirements, duplicative documentation and misaligned incentives have made even routine…