How Healthcare Payers Should Leverage LLM Solutions for Operational Efficiency and Cost Reduction
The healthcare industry is undergoing a rapid digital transformation, driven by advancements in technology and the increasing pressure to improve […]
Healthcare Operations
CMS Reminder to Practice Vigilance Against Medicare Fraud, Waste and Abuse
On April 15, 2022, the Centers for Medicare & Medicaid Services (CMS) released potential fraud, waste and abuse (FWA) trending
Streamlining Medicare Advantage Organizations Member Communication: A Guide to CMS’s Model Materials for CY 2025
Every year, Medicare Advantage Organizations (MAO)1 must update their member communication materials, such as the Annual Notice of Change (ANOC),
Navigating the Intersection of Payment Integrity and Provider Relations in Healthcare
Payment integrity and provider relations are two critical pillars of a well-functioning healthcare system. When effectively managed, they can lead
Medicare Part D Risk Adjustments and Bidding Instructions for 2025
The Centers for Medicare & Medicaid Services (CMS) uses the Hierarchical Condition Category (CMS-HCC) medicare risk adjustment model to determine
Medicare Advantage Overpayments: Are You Ready for RADV Audits?
In recent news, the healthcare industry has been abuzz with significant developments that carry vital lessons for Medicare Advantage health
Preparing for 2024: Essential Compliance Checklist for Medicare Advantage Organizations
The Annual Election Period (AEP) has ended. Before the Medicare Advantage Open Enrollment Period (MA OEP)[1] begins on January 1, 2024,
The Transformative Power of GenAI in Compliance and Operations
As a former U.S. healthcare operation management professional, I understand the complexities and dynamic nature of the healthcare compliance landscape.
2023 CMS Audit Protocols: What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) has released new audit protocol changes for Medicare and Medicaid plans. These
ACA Health Plans — Key considerations for staying relevant
A perspective on recent industry shifts influencing ACA plan operations in states, which are yet to adopt ACA Medicaid expansion