PayerFusion Healthcare Insights Roundup – January

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February 1st, 2013

15 Types of Medical Billing Fraud & Abuse

It is estimated that medical fraud and abuse accounts for $80 billion worth of healthcare costs in the US. Fraud and abuse can also cause serious harm to patients subjected to unnecessary or inappropriate medical services. Learn about 15 types of medical fraud and abuse affecting payers, patients and the healthcare system as a whole.

Health Plan Design Trends for 2013

As the healthcare landscape transitions, self-funded employers and insurers are reassessing their health plan designs to better cope with costs and impending changes. In this post we review 5 health plan design trends employers are considering in the year going forward.

PayerFusion Expands Reach of Health Plan Administration Services Across the USA

PayerFusion Holdings LLC, a leader in health plan administration and cost containment, announced today the expansion of administrative services to 16 US states. This significant achievement is a result of successfully completing the extensive third-party administrative licensure and business registration process for the states of AK, CA, CO, DC, FL, HI, IL, IN, IA, KS, KY, MA, MI, NE, RI and VA.

CT Scans and Cancer Risks

The use of CT scans (and medical imaging in general) is rising and with it the amount of patient exposure to radiation. A recent JAMA study found that the rate of CT scan use had increased by 20% between 1996 and 2010. The extreme amount of radiation in CT scans has the potential to cause irreparable damage to DNA and ultimately lead to cancer.

The Benefits of Medical Case Management

Through proactive approaches, medical case management helps benefit patients, providers and payers by reducing healthcare costs, coordinating care and improving patient satisfaction. Case Management can be defined as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs.

Bundled Payment Models for Acute & Post-Acute Care

The growing implementation of bundled payment models in the US healthcare system will likely continue and is seen as a key strategy to improving quality and reducing costs. In this post, we summarize three models of bundled payment initiatives that are currently being utilized and developed.

Primary Care: The foundation of a strong healthcare system

A solid and well-equipped primary care foundation is of key importance to developing a better healthcare system. In health systems and communities across the world, utilization of primary care is shown to lead to better overall health outcomes, reduce inappropriate utilization, promote a focus on preventative care and reduce hospital readmission.

The Negative Impacts of Fee-For-Service Payment

Changing our healthcare system requires that we change the way we pay for medical services. Fee-for-service (FFS) is seen as one of the most significant drivers of healthcare cost and quality issues. The incentive FFS creates to increase volume of services is just the beginning of the negative impacts on the healthcare system.

Stop-Loss Insurance for Self-Funded Employers

Self-funding of health benefits has become a viable option for many employers who seek the benefits of reduced costs, greater plan design flexibility and exclusion from PPACA provisions. A critical component of a self-funded plan is the selection and implementation of stop-loss insurance.