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…
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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…
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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…
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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…
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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…
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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…
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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…
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Payers and providers are widely using AI — but most aren’t seeing full value. Despite near-universal adoption, a nationwide survey conducted with Becker’s Healthcare found fewer than half of organizations are fully committed to using AI to transform outcomes and…
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Health plans are facing rising claim volumes, staffing challenges, and a surge in rework. Traditional automation, tied to individual applications, can’t keep up. Agentic automation offers a better way. By unifying AI agents, software robots and humans in a coordinated…
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Musculoskeletal (MSK) conditions now cost the U.S. more than $420 billion, yet many payer-led interventions fail to engage patients early enough to prevent low-value procedures and rising costs. This new report from TailorCare shows what happens when patients are guided…
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