For healthcare organizations and providers involved in a Medicare Shared Savings Program (MSSP), 2025 is truly a time of transition and a little uncertainty. When colleagues recently asked for my thoughts on MSSP this year, the old saying “May you live in interesting times” kept coming to mind.
Prior authorization can cause serious issues for members and providers if processes are not properly architected by a healthcare payor. More than nine in 10 physicians (94%) reported care delays while waiting for health care insurers to authorize necessary care, a physician survey by the American Medical Association found. Eighty percent said prior authorization can...
In the last few years, challenges related to prior authorization have created inefficiencies in health care that negatively impact both health outcomes for members and the costs both payers and members must pay. That’s why in December 2022, the Centers for Medicare & Medicaid Services (CMS) proposed Rule CMS-0057-P. The new rule is designed to...
In theory, utilization management (UM) should reduce the overall cost of care while improving outcomes for health plan members. But for many payers and providers using homegrown solutions and outdated, siloed platforms, the reality is much different. Without the ability to sync and share data across teams and departments, it’s nearly impossible to gain a...
Expedite Patient Care and Reduce the Burden Between Payers and Providers with Edifecs Automated Prior Authorization Solution Prior authorization has long been a burden across the healthcare industry, impacting payers, providers, and patients alike. Although a well-intended tool for utilization management (UM), prior authorization has often come under fire for creating extra red tape, resulting...
The term “payvider” isn’t new. It’s part of the inspiration behind our HELIOS platform – to enable and support value-based partnerships between payers and providers. But in recent years, the desire of health systems to become involved in risk management has increased. A survey in 2021 found that nearly 60% of health systems aimed to...
A good UX (user experience) is a key player in how quickly a care management platform is adopted and how successfully it’s utilized. Adoption and usage are key concerns for healthcare organizations when choosing a medical management platform. This is especially true for those with large teams of care managers or case managers who need...
For healthcare organizations, CMS-0057-F outlines the modern healthcare system and offers opportunities to improve care and utilization management In the last couple of years, the Centers for Medicare & Medicaid Services (CMS) have been making strides to increase health data exchange, as well as improve and expand access to care. On January 17, CMS finalized...
As a new year approaches, the U.S. healthcare industry faces converging factors that signal some significant upcoming changes. An estimated 60% of adults have at least one chronic disease, and 40% suffer from two or more, straining healthcare resources. In 2023, life expectancy declined to 76.4 years, due in part to social inequities and to...
