Current Trends For Payers

Latest Episodes:

No Analysts Needed Jul 01, 2025

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Health plans continue to face operational delays due to fragmented systems and an over-reliance on manual reporting cycles. While data analysts work across multiple platforms to produce static reports, the insights often arrive too late to support real-time decisions. This episode explores why traditional models are no longer sustainable and how self-service dashboards, powered by a connected data ecosystem, are transforming operational agility. Listeners will hear how prebuilt metrics provide immediate visibility across functions such as claims, call center performance, and ID card fulfillment, enabling teams to respond faster, stay compliant, and enhance member outcomes. The discussion also covers adoption strategies, ROI considerations, and the organizational shift toward on-demand, decision-ready data.

Listen now to discover how leading health plans are moving from reactive operations to real-time insight, without relying on analysts.

About Our Guest:

Michael Waxman is a health plan operations leader with over 20 years of experience as a health payer consultant at PwC and EY. He recently served as the Director of Business Operations for the post-implementation operations of a technology ecosystem for a Medicare Advantage client. Using a self-service dashboard, he ensured operational alignment for the health plan’s provider data, claims, credentialing, cross-functional alignment for call center, disputes, utilization management, and more.

RADV Acceleration: What It Means for Medicare Advantage Plans Jun 06, 2025

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CMS has issued a major announcement that’s reshaping how Medicare Advantage plans approach risk adjustment audits. A new era of oversight is here. Defined by tighter timelines, expanded audit scope, and heightened expectations around data accuracy. Along with the announcement, a detailed compliance memo introduces new submission deadlines that demand immediate attention from health plans. This shift has wide-reaching implications for compliance strategy, resource allocation, and revenue protection.

In this bonus episode, we unpack what’s changed, why it matters, and what plans need to consider next. Listen now.

About Our Guest:

Amanda Proctor is the Director of Coding Quality and Risk Mitigation and has over 14 years’ experience in Risk adjustment and holds multiple certifications in Coding, Auditing, and Compliance and is an AAPC Approved Instructor. She specializes in Risk Mitigation, RADV Audits, Coding Compliance and Education.

From Siloes to Synergy: The Power of Data Hub Jun 02, 2025

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In this episode, we explore how data consolidation is reshaping health plan operations and why it is becoming essential for the future of the industry. From breaking down data silos to enabling real-time, data-driven decisions, data hubs offer health plans a scalable solution to improve efficiency and streamline processes. Discover the challenges health plans face today and how a data-centric ecosystem can unlock powerful insights, enhance member engagement, and drive cost savings. Tune in to learn how data connectivity across your plan’s technology ecosystem can revolutionize your operations.

About Our Guest:

Adam Fenech is Vice President of Product. He has been in healthcare leadership for over 20 years, on both the payer and provider sides of the business. Adam has a degree in Computer Information Systems and has deep expertise in core administrative products and processes, as well as the emerging industry shift to a data-centric technology ecosystem model.

Removing Data Silos For A 360-Member Journey May 02, 2025

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Payers are seeking new ways to enhance member engagement and drive long-term retention.

This podcast explores a powerful new-to-market strategy for transforming how health plans design member journeys to create a seamless experience in a combination of offline and online environments.

Don’t miss the insights in this episode that will redefine how your plan approaches member engagement.

About Our Guest:

Barb Ody is a payer consultant and expert in member experience solutions, technology and process implementations, clinical business informatics, data modeling and analysis.

The Human Side of Workflow Technology: Claims + Enrollment Processing Apr 02, 2025

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Claims and enrollment management can feel like a juggling act, especially with rising volumes and the pressure to meet strict accuracy and timeliness standards. What if there were tools to simplify it all? In this episode, we dive into the game-changing power of modern workflow solutions. Discover how these tools eliminate inefficiencies, prevent cherry-picking by claims and enrollment processors, and streamline auditing, all while boosting internal team communication and productivity. Whether your health plan claims and enrollment teams are struggling with manual processes or looking to scale without adding staff, this discussion offers practical insights you can’t afford to miss. Tune in to learn how to transform your claims and enrollment management strategy!
About Our Guest:

Alison South is the Vice President of revenue enablement and a subject matter expert in payer technology and operations. She brings 20+ years of experience in health plan operations, overseeing operational readiness, learning and development, and quality and audit operations. She has worked for large national payers running government programs, including Medicare and State Medicaid Demonstration programs and military healthcare operations.

Rethinking Total Cost of Ownership In Core Admin Mar 04, 2025

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Health plans often underestimate the full financial burden of their core administration systems. This episode shines a light on the hidden costs buried and spread throughout the lifecycle of a typical core admin vendor contract. We will discuss what total total cost of ownership is, how to evaluate it, and what to do when costs are unexpectedly higher than you anticipated due to spread-out expenses, complex integrations, and recurring upgrades. Listeners will learn how to identify the operational “patchwork” that keeps plans tethered to legacy models and discover why taking a shorter, more honest view of long-term costs can reveal hidden savings. The conversation explores how integrated ecosystems provide stability, transparency, and scalability, positioning plans to invest in growth rather than wasting unoptimized resources.

Achieving a Compliant Query Practice Feb 03, 2025

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Clinical documentation improvement (CDI) is essential for accurate patient care, compliance, and effective risk adjustment. Health plans and providers must work together to address common challenges like incomplete records, workflow disruptions, and slow technology adoption. By integrating solutions that fit seamlessly into provider workflows—whether through EMR-compatible platforms or flexible engagement models—health plans can reduce administrative burdens while ensuring compliance with CMS guidelines and HIPAA requirements.

This episode explores best practices for health plans to support providers with clinical documentation and how proactive risk adjustment strategies improve efficiency by addressing documentation gaps upfront, reducing costly retrospective corrections.

Listen to this episode to learn how to build a stronger partnership between health plans and providers, improve compliance, and enhance operational efficiency.

About Our Guest:

Keicia Hutchinson has been in the healthcare industry for over 18 years specializing in medical billing, Medicaid and Medicare auditing, and clinical documentation improvement. She is a member of AAPC and holds credentials in COC, CPC, CPC-P, CDEO, CPMA, and CRC.

Tech Ecosystems: The New Operating Model Jan 07, 2025

Show notes

In this episode, we discuss the history of tech ecosystems for health plans, the most common operating model today, the multiple-vendor model, and an innovative new operating model that relies on an end-to-end ecosystem from a single, accountable vendor partner. We discuss the pros and cons of the different models, as well as provide recommendations for future-forward plans that are ready to improve the delivery of healthcare and reduce the inefficiencies native to the industry.
About Our Guest:
Kevin Adams is the co-founder and CEO of UST HealthProof and now HealthEdge. Under his leadership, strategic vision, and commitment to innovation, UST HealthProof has grown into a global organization with over 4,000 employees. Kevin served as the healthcare Chief Technology Officer for UST Global and has held roles with Cigna and Accenture. He also led the digital transformation effort at Edifecs.

Lessons Learned From the OIG Dec 02, 2024

Show notes

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 Guest
Kristi 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.

From Data to Action: Revolutionizing HEDIS Analytics Nov 04, 2024

Show notes

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 Guest
Sharon 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.

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