Current Trends For Payers

Accurate coding in healthcare is critical, especially with the recent changes brought about by the RADV extrapolation rule. This regulation allows the Office of the Inspector General (OIG) to apply audit findings from a sample across an entire Medicare Advantage plan, significantly increasing the financial risks associated with coding errors. For example, a $500,000 penalty for mistakes in coding can now balloon to millions, making it essential for health plans to prioritize coding accuracy and compliance.To navigate these challenges, the OIG has developed helpful resources that guide health plans in identifying high-risk diagnosis codes and highlighting common mistakes to avoid. Organizations can leverage this information to enhance their coding practices and protect themselves against potential audits. Tune in to learn more about effective strategies and resources to improve coding accuracy and compliance in your organization. About Our GuestKristi Reyes is the Director of Risk Adjustment Coding Operations. She leads a team of medical coders from various aspects of risk adjustment—including retrospective, prospective, CDI, QA, risk mitigation, and RADV. Kristi holds certifications in Certified Professional and Outpatient Coding, Risk Adjustment Coding, and Auditing.Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

This episode explores the challenges and opportunities plans face during the digital transition. The most common challenges are outdated systems, fragmented data sources, and managing data integration effectively. We discuss innovative strategies to reshape HEDIS reporting and analytics—from integrating diverse digital data into a unified platform to accelerating processing speeds for real-time insights. Plans can leverage these powerful analytical tools, flexible reporting, and actionable data to proactively identify care gaps, deploy intervention campaigns, streamline workflows, and ensure regulatory compliance. This episode equips health plan leaders with the strategies they need to stay competitive and fully embrace the latest industry strategies for HEDIS success. About Our GuestSharon Kurht is the Director of Quality. She has 14 years of experience in HEDIS, Medicare Stars, and Medicaid. Sharon is an RN who holds a doctorate in nursing from Northeastern University, where she is also a health informatics professor at the graduate level. Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

The 2025 Medicare Advantage and Part D Star Ratings were released on October 10, 2024. This year brought significant shifts that will impact health plans across the industry. With new challenges in place and more stringent performance measures, it’s essential for health plans to understand how these changes have affected Star Ratings. The introduction of updated methodologies, such as the use of Electronic Clinical Data Systems (ECDS) for certain measures, and increased weight on critical performance areas, are just a few of the factors reshaping the ratings landscape.Looking ahead, plans need to stay ahead of the curve as Star Year 2026 and beyond bring even more changes. New measures, adjusted weights, and upcoming initiatives like the Health Equity Index will play a major role in future performance. Discover key strategies to prepare your plan for these changes and ensure your Stars strategy is built for success. For a deeper look at what’s ahead and expert insights on how to stay competitive, listen to the Bonus Podcast Episode: Star Ratings 2025 Industry Report.Thank you to our sponsor, usthealthproof.com—unburdening the healthcare experience. 

Preparation and a vigilant organizational mindset are critical to reducing the financial and reputational risk of cybersecurity incidents.  Join CISO, Hans Guilbeaux for an in-depth discussion on ways health plans can ensure their vendors have implemented industry best practices and are prepared for incident response with detailed disaster recovery and business continuity processes.About Our Guest:Hans Guilbeaux is the UST HealthProof CISO and has over 25 years of experience in network and infrastructure engineering, security systems administration, network penetration, vulnerability assessment, IT auditing, incident response, and forensics investigation. Hans is a Certified Information Systems Security Professional (CISSP), and a Certified CSF Professional (CCSFP). Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.