Payer

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…

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…

Many self-funded organizations are still making high-stakes benefits decisions without timely, actionable data. That gap is becoming more costly as employer healthcare expenses are projected to rise 8% in 2025, marking the steepest increase in a decade. This report examines…

For health plans and health systems, care gaps present clinical, financial and operational challenges. Missed screenings, fragmented communication and outdated outreach methods put incentive dollars, member trust and Star Ratings at risk. But some organizations are finding a way forward.…

Despite rising spend, the U.S. continues to lead the developed world in maternal mortality. But one health plan is proving it’s possible to reverse this trend — and reduce costs at scale. A leading health plan responded to growing demand…

High call volumes. Long resolution times. Burned-out agents. For payers, traditional contact center tools aren’t enough to meet today’s member expectations. Generative AI is changing that — and some of the most complex service organizations in the world are already…

Underwriting accuracy hinges on speed, consistency and a clear view of changing risk. When new business, renewal and population health workflows run on different tools, teams face slow quotes, inconsistent pricing and limited insight into what’s driving costs. This report…

Delayed wound care drives avoidable costs — and for payers, those costs can be substantial. Each year, U.S. health plans spend billions on wound-related treatment, complications and prolonged care episodes. New real-world data from more than 15,000 patients shows how…

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) represents a significant compliance lift. However, payers have the opportunity to leverage the rule as a means to accelerate broader transformation. From streamlining prior authorizations to integrating clinical, claims and SDOH…

With CMS-0057 on the horizon — and growing friction with providers and members — health plans know utilization management needs more than a tune-up. But fragmented systems, outdated policies and poor access to clinical data continue to slow progress. In…