Payer

AI agents are already processing prior authorizations, adjudicating claims and driving member outreach at scale. But an agent is only as trustworthy as the data grounding it. When member identities, benefits and authorizations are fragmented, agents make confident but wrong…

Preference-sensitive surgeries — like spine fusions, hip replacements and cataract surgeries — represent a significant and often underestimated source of payer medical spend. Yet most health plans have no clear line of sight into this category. Because these procedures cut…

As Medicare and Medicaid oversight intensifies, health plans are navigating a more complex landscape where policy ambiguity, state variability, and heightened enforcement are exposing gaps between intent and execution. Prepay strategies are gaining momentum as they prevent avoidable spend before…

The problem usually isn’t the clinical strategy. It’s what happens after the strategy is approved. When priorities blur, ownership fragments and progress goes unmeasured, even well-designed plans stall before they reach members. The downstream effects — avoidable utilization, missed engagement…

GLP-1 utilization is climbing and so are the costs. For payers and employers, the instinct is to restrict access, layer on prior authorizations and focus narrowly on pharmacy spend. The problem with that approach is it often backfires. Members discontinue…

Behavioral health claims have long operated outside the scope of traditional payment integrity programs. As volume increases, and error rates can approach 50 percent, this gap is becoming harder to ignore. At the same time, parity enforcement is intensifying, creating…

For a growing share of members, the care journey now begins not with a nurse line or portal, but with AI. Conversational tools are stepping in before a clinician is involved, guiding symptom interpretation and next-step decisions. While this shift…

This webinar is on-demand and can be viewed at your convenience.  Prior authorization continues to create friction between payers and providers, slowing decisions and increasing administrative burden. New interoperability expectations, including CMS-0057-F, are accelerating the need for more connected, transparent…

Risk adjustment strategies built on retrospective chart chase are no longer just inefficient — they are increasingly financially exposed. As RADV audits expand and regulatory scrutiny intensifies, payer organizations are being forced to rethink not just how risk is captured,…

Many payer-provider partnerships start with strong alignment but fail to deliver sustained results. In this webinar, leaders share what it takes to move from intent to execution — building trust, aligning operations and delivering consistent value across markets, provider types…