Payer

The line between inpatient admission and observation care is one of the most consequential decisions in hospital medicine. For payers, it sits at the center of medical necessity disputes, length-of-stay variability and post-payment audit risk. This white paper walks through…

Cancer outcomes have improved but delays and fragmentation still define much of the care journey. Patients wait an average of 156 days between screening and diagnosis, and every four-week delay can increase mortality risk by 6 to 8 percent. For…

Tens of millions of average-risk adults remain overdue for colorectal cancer screening, even as colorectal cancer has become the leading cause of cancer death among Americans under 50. Traditional mailed FIT programs often struggle to sustain engagement, complete follow-up colonoscopy…

Most payer organizations agree AI will reshape underwriting, claims and operations. But many initiatives still struggle to move beyond isolated pilots. The challenge is no longer whether AI matters. It’s how to operationalize it responsibly. This new white paper examines…

Members with serious illness often experience fragmented care, avoidable hospitalizations and repeated emergency department visits before receiving meaningful support. For health plans, the result is rising utilization, higher costs and growing pressure to improve quality performance across Medicare, Medicaid and…

2026 marks an unprecedented convergence of forces that will reshape the market landscape: This executive brief reveals why traditional gap closure programs are failing and how diagnostic intelligence enables the shift from retrospective campaigns to continuous, real-time quality management. Healthcare…

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…

As 2027 approaches, Medicare Advantage plans are navigating tighter margins, increased oversight and higher expectations for accuracy. They are entering a more constrained environment where performance, not volume, will determine financial outcomes. From expanded RADV audit exposure to tighter expectations…

Providers are paying closer attention to how — and how quickly — they get paid. Every delay, reconciliation issue or administrative hurdle contributes to a growing burden that affects how providers engage with payer organizations. Forward-looking payers are responding by…

Behavioral health care is under growing financial and operational strain. Despite increased spending, fragmented care models, access challenges and fee-for-service structures continue to limit outcomes and drive unnecessary emergency visits and hospitalizations. Patients, providers and payers are left navigating disconnected…