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Blogs

Assessing Uncertainty: The Impact of Policy on Medicaid & D-SNPs

Changes in federal and state leadership, regulatory priorities, and budgetary negotiations are reshaping the ground beneath payers’ feet. At the same time, health plans are navigating a market defined by margin pressure, demographic shifts, and integration mandates. Even modest regulatory adjustments like eligibility verifications, matching-rate recalculations, and D-SNP alignment rules can significantly alter enrollment dynamics and financial projections. Evaluate how today’s evolving political environment is redefining Medicaid and D-SNP markets and how health plans and MCOs can stay resilient amid uncertainty.

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Blogs

2026 Medicare Physician Fee Schedule: Key Impacts for HMO Contracting

The 2026 Medicare Physician Fee Schedule (MPFS) arrives at a complicated moment for health plans. Leaders are still managing the financial drag from the 2025 conversion factor cut, network pressures tied to staffing shortages, and quickly shifting behavioral health and digital care models. The new MPFS rule introduces changes that may look incremental on paper, but together they impact how health plans will need to approach pricing, contracting, and operational planning for the next several years.

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Blogs

Compliance & Accreditation Amid Policy Shifts: CMS Updates & Operational Readiness

As CMS finalizes sweeping updates to utilization management, supplemental benefits, and member communication requirements, compliance and accreditation leaders find themselves at the intersection of policy interpretation and operational accountability. These changes arrive alongside a shifting accreditation landscape in which NCQA, URAC, and other entities are tightening expectations around transparency, documentation, and cross-departmental governance. The challenge is translating the rules into procedures that hold up under audit, maintain accreditation standards, and deliver clear, consistent experiences for members and providers. This period of regulatory recalibration demands a proactive approach that ties compliance planning directly to enterprise readiness and performance outcomes.

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eBooks

How to Prepare for CMS-0057-F

The Interoperability and Prior Authorization Final Rule (CMS-0057-F) introduces new technology standards and faster decision timelines designed to improve efficiency, transparency, and patient access. Review the compliance timeline and learn how to prepare for CMS-0057-F so your team can effectively modernize processes, better engage providers, and elevate member experiences.

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Blogs

FHIR Prior Authorization: A Compliance Playbook for Health Plans

FHIR®-based prior authorization is becoming one of the most significant areas of regulatory focus for Medicare Advantage, Medicaid, and commercial payers. Requirements tied to the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) are accelerating the shift toward digital, structured, and highly coordinated exchange of clinical information.1 For managed care organizations and health plans, this shift affects technical infrastructure, data governance, and daily operations across utilization management, member services, and provider experience teams. Review the high-level playbook health plans should use to take a practical, readiness-oriented approach and move from awareness to execution.

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Blogs

Transformation at Scale: AI-Enhanced RCM & Utilization Management

Artificial intelligence is being used to bring structure and speed to administrative processes, helping plans make more informed decisions and reducing the manual burden across both RCM and UM. When deployed strategically, AI lets these two areas share intelligence, anticipate risk, and align on quality and efficiency targets, which changes how plans scale operations without sacrificing oversight. Examine how AI-enhanced RCM and UM can work in unison to deliver measurable transformation at scale and define the next era of payer performance.

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