Payer

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…

After an abnormal cancer screening, it takes an average of 156 days to reach diagnosis — a delay that increases costs, worsens outcomes and exposes gaps in care. This report outlines a new model: shifting clinical intervention earlier in the cancer…

Eight out of ten Americans turn to search engines or general-purpose LLMs at least once a month for medical questions. Yet physician-led evaluations show some AI chatbots deliver unsafe or harmful responses in up to 43% of cases, creating new…

Nearly half of consumers access healthcare portals less than once a month, and 16% say they have never used one. For payer organizations investing heavily in digital member portals, this gap between availability and engagement raises an important question: What…

Consumer demand for virtual care continues to grow — and expectations are expanding beyond episodic care. New research shows insured adults are increasingly open to using virtual care across a broader range of needs, yet real‑world use has not fully…

Musculoskeletal conditions are among the largest cost drivers for Medicare Advantage plans. As populations age, surgical interventions and downstream utilization continue to drive spending — even when conservative care options may be appropriate. A new analysis of Medicare Advantage members…

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…

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…