Current Trends For Payers

Latest Episodes:

Star Rating Industry Report 2025 Oct 16, 2024

Show notes

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.

About Our Guest: Patricia Graunstadt is an expert analyst in the Star Ratings and quality space. Her team tracks Star program changes and develops initiative offerings and long-term strategies for reaching and maintaining 4-Star Ratings. Patricia has worked with various clients, analyzing all Star measure data and providing accurate projections of plan performance. She holds an Industrial and Operations Engineering degree from the University of Michigan.

Cyber Security Trends: Third-Party Security Assurances Oct 01, 2024

Show notes

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 a Chief Information and Security Officer with 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).
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Why Retrospective Risk Is Administratively Heavy—And What To Do About It May 08, 2024

Show notes

Retrospective risk adjustment involves several administratively heavy processes, from chart retrieval to coding to supplemental data and submissions. The ever-changing regulatory environment requires continual updates in processes and technology.
Discover ways to streamline retrospective risk adjustment processes and develop a strategic, multi-faceted approach to addressing industry changes.

About Our Guest:
Greg is the Managing Director of Risk Adjustment Operations, leading a team of over 350 risk adjustment professionals to drive client execution, customer value, and plan revenue optimization.

Prior Authorization Trends & Opportunities Apr 01, 2024

Show notes

Prior authorization plays an important role in maintaining clinical quality, preventing fraud, and ensuring medical necessity—but its administrative burden has prompted the industry to rethink certain requirements and accelerate the adoption of automated approvals and Gold Carding.

For these solutions to succeed, payers must encourage provider adoption with intuitive platforms, user-friendly interfaces, and seamless workflows. Streamlined prior authorization can reduce friction, support timely care, and create a better experience for payers, providers, and members alike.

Tune in to explore how the industry is reducing administrative burden without compromising quality, how health plans are using technology and data to refine prior authorization, and what CMS is doing to promote appropriate guidance and timely decisions that put members’ best interests first.

About Our Guest:
Chris Hugenberger has been in healthcare software for nearly 20 years, working on operations, implementations, and product development for both the provider and payer sides. He has niche expertise in utilization management and prior authorization software.

Responsible AI For Payers Mar 04, 2024

Show notes

As payers integrate artificial intelligence into healthcare operations, responsible AI governance is essential to protect patients and support sound decision-making. AI can improve efficiency, speed, and accuracy at scale, but it should never operate without human oversight. Leaders and stakeholders must understand how an algorithm reaches conclusions, which data informs its recommendations, and where bias or other risks may arise.

This episode explores the challenges of using AI for decision support, the principles of transparency, accountability, and safety, and the information stakeholders need to evaluate AI responsibly. Tune in to understand how health plans can embrace innovation without sacrificing trust, safety, or accountability.

About Our Guest:
Sam Keith is an expert in data science, marketing, and analytics. He has over 18 years of experience working in the technology product space, leading product development teams and initiatives to support consumer engagement, user experience, digital experience, and operations. Sam has worked in healthcare, higher education, pharmaceutical, and network security industries and is particularly interested in digital accessibility practices.

Unlock The Potential of Prospective Programs Feb 05, 2024

Show notes

As more and more provider organizations enter into risk-sharing agreements, provider engagement programs are experiencing a surge in participation. Provider engagement programs improve the collaborative relationship between plans and providers to keep documentation up-to-date for CMS submission. It's essential for plans to offer a variety of delivery methods to suit the provider's practice. Some practices enjoy an in-person, on-site method to receive personalized guidance for education and to maximize documentation opportunities, while other practices enjoy an EMR-integrated solution for a highly efficient digital workflow. Providers with an already established process for responding to queries may prefer a remote option via fax. The important aspect of a healthy provider engagement program is not necessarily the delivery method but rather the timely and continuous communication between plans and providers to close gaps on addressable conditions.
Tune in to discover the best practices for running a successful provider engagement program.
About Our Guest:
Michelle Calagaz is an expert in prospective risk adjustment programs specializing in provider engagement tactics. She has over 30 years of experience working in healthcare with a focus on Medicare Advantage initiatives and has an array of experience across risk adjustment, business operations, program implementation, product development, and client relations.

NLP For Coding & Compliance Jan 04, 2024

Show notes

Natural language processing (NLP) is transforming healthcare IT by helping medical coders identify diagnoses associated with HCC risk-adjustment categories—especially within medical charts that can span thousands of pages. By surfacing relevant codes for review, NLP can improve speed, efficiency, and productivity while supporting quality assurance and compliance.

But technology alone isn’t the whole story. What are NLP’s biggest opportunities and limitations? Why are skilled medical coders more important than ever? And how do organizational priorities influence the way health plans customize their NLP systems?

Listen to this episode to discover how NLP is reshaping medical coding and unlocking new possibilities for health plan operations.

About Our Guest:
Kristi Reyes is the Director of Risk Adjustment Coding Operations. She leads a team of 250 medical coders from various aspects of risk adjustment—including retrospective, prospective, CDI, QA, risk mitigation, and RADV. Kristi holds Certified Professional and Outpatient Coding, Risk Adjustment Coding, and Auditing certifications.

RADV—The Future of Reimbursement Accuracy Dec 01, 2023

Show notes

RADV audits were created to ensure Medicare Advantage payments are accurate—but their history reveals how significantly the stakes have evolved. From early payment reforms to CMS’s plans to extrapolate overpayments, health plans face increasing scrutiny and uncertainty around error-rate methodology, timelines, and financial exposure.

What does this mean for Medicare Advantage organizations, and how can they prepare before extrapolation begins? This episode explores the evolution of RADV audits, the implications of CMS’s latest rules, and practical ways health plans can strengthen risk mitigation, improve reimbursement accuracy, and better forecast potential liabilities. Listen now to learn how to prepare for what’s ahead.

About Our Guest
Amanda Proctor has over 13 years in risk adjustment coding and specializes in risk mitigation, coding quality and education. She holds multiple certifications in coding and is an AAPC approved instructor.

Regulatory Concerns In Enrollment Technology Nov 01, 2023

Show notes

Enrollment technology designed around CMS regulations gives Medicare Advantage and Part D plans important advantages. Real-time integration with the CMS MARX database can validate Part A, B, and D eligibility faster than batch processing while accounting for special election periods. Automated workflows can also identify incomplete applications, request missing information, and update downstream systems when enrollment changes. Because enrollment is a member’s first interaction with a plan, the technology should connect seamlessly with claims processing, vendors, and correspondence. In this episode, discover how smarter enrollment systems can improve compliance, streamline operations, and create a more connected member experience from the start.

About Our Guest:
Dave Laity is the Product Director for Enrollment and Billing products. Dave has nearly 20 years of healthcare experience that include the development of enrollment solutions that focus on Medicare Advantage and Part D.

Bonus Episode: Star Ratings Industry Report 2023 Oct 25, 2023

Show notes

Tune in for an in-depth review of the recent Star Ratings release. On October 13, 2023, the 2024 Medicare Advantage and Part D Star Ratings were published on Medicare Plan Finder, largely representing Measurement Year 2022 data submitted to CMS.
We discuss the variables that influenced performance and why it's the second year in a row that average Star Ratings have declined, and some plans might be seeing less-than-ideal performance. More than a third of plans saw a decline in Star Ratings this cycle.
Tune in to learn about the changes that will impact 2024 performance, including the Tukey Outlier Deletion Method, the transition of several HEDIS measures to Electronic Clinical Data Systems (ECDS), measure weight changes, and more.

About The Expert
Megan Piotrowski is a Star Ratings and quality strategy manager evaluating market trends and the competitive landscape to develop initiative offerings and long-term strategies for the continued maintenance of 4-Star Ratings. Megan has held a variety of regulatory, quality leadership and consultant roles across the continuum of healthcare. She’s led the quality improvement initiatives on behalf of health plans across all lines of business, as well as for health systems, providers, and community and government-based organizations. She holds a Master of Science in Health Informatics from Northwestern University.

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