Insurers: How to Lead in the New Era of Connectivity Bain & Company

The Medicare Advantage (MA) option (Medicare Part C) continues to grow.3 Under MA, CMS contracts with private payers—those same insurance companies—and uses their networks, shifting financial risk to that plan. To be in-network in an MA plan, you must have a contract with that payer and follow that payer’s policies. CMS is also contracting with ACOs and has moved forward with the Bundled Payment Care Initiative (BPCI), which also financially rewards entities that manage the care of populations of patients. To benefit financially, you must be a member or have a contractual arrangement with the ACO or entity that has the CMS BPCI contract. This is an issue for neurologists in all practice settings, including solo or small private groups, multispecialty groups, academics, or hospital employed. In the near future, most of us will be part of accountable, coordinated care programs that place us at financial risk and make us responsible for managing populations of patients.

A defining trait in such arrangements, compared with standard forms of provider-health plan collaboration, is the emphasis on delivering value through efforts to increase access, improve quality and reduce waste, said Michael Nugent, partner with Guidehouse. Historically, the objective of a provider-health plan joint venture tended to be to offer “just a unit cost discount” for customers, Nugent said. As healthcare stakeholders consider how to make value a more central focus of care-related services, one result is a blurring of the lines between providers and payers. The Healthcare Service resource typically describes services offered by a Pharmacy or Pharmacy Organization. A Location is the physical place where healthcare services are provided, practitioners are employed, organizations are based, etc.

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Because insurers interact with their customers so infrequently, they often lack the quantity and quality of data they need to generate meaningful insights about what their customers want. And, compared with companies in such industries as banking and healthcare, insurers have underinvested in data analytics and IT, when measured against annual revenues, according to Gartner. These trends are particularly evident among millennials, the large global cohort of consumers 18 to 34 years of age. These young people, who tend to be heavy users of connected devices, make up 37% of the working-age population in the 16 countries we surveyed; in India the figure is 47%.

  • The federal Centers for Medicare & Medicaid Services (CMS) and the Joint Commision on Accreditation of Healthcare Organizations both require that healthcare providers be credentialed.
  • When the provider is a practitioner, there may also be a relationship to an organization.
  • Another tool to assess the risk of FTC scrutiny is to calculate pre- and post-merger market concentration levels.
  • From these customer ratings, we determined how much value a company created both overall and for individual elements.
  • CMS is also contracting with ACOs and has moved forward with the Bundled Payment Care Initiative (BPCI), which also financially rewards entities that manage the care of populations of patients.

The issue of Medigap eligibility should be considered by clients looking to switch from Medicare Advantage to traditional Medicare. Clients looking to switch from one Advantage plan to another should compare the new plan’s cap on out-of-pocket costs to the limits on their current plan. Whether this is a reason to either switch Medicare Advantage plans or to consider moving to traditional Medicare will depend on your clients’ situation.

Provider frequently asked questions (FAQ)

Department of Justice (DOJ) and FTC both enforce Section 7, the FTC is responsible for the vast majority of merger investigations and enforcement actions involving healthcare providers. State attorneys general often join the FTC in its investigations and litigation. Moreover, while the FTC and DOJ typically seek to block transactions prior to consummation, Section 7 permits the agencies to challenge—and unwind—transactions post-consummation.

How to Connect to Healthcare Providers and Insurers

Guidehouse also analyzed markets to see where performance on value may be lagging (based on cost, utilization, quality and patient satisfaction data). That’s an indication that a high-performing new entity could make a big impact. This policy has exclusions, limitation, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable). If you already have a plan, you can call the number on your member ID card or sign in to your health plan account and go to Benefits & Coverage to review what’s covered under your plan. You’ll usually give information about yourself, and other family members covered under your plan.

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Contact Experian Health today to improve your pre-approval processes with electronic prior authorization software. Insurance is on the cusp of a new era, one characterized by customers who are connected by devices, digital platforms, and the quest for products and services that are easy to understand, compare, purchase and use. They are cautiously willing to share with insurers the data from the devices in their homes, in their cars and on their bodies, provided they believe they will receive something of value in return. If an insurer is not delivering value, customers will switch to one that is, most likely to another incumbent, for now. But our survey also shows customers are very open to trying out new entrants, including those from outside the industry. Insurers that sell directly to consumers, without using an agent or other intermediary, are taking the lead in developing digital strategies.

How to Connect to Healthcare Providers and Insurers

Investing in digital channels is not enough, Insurers must create omnichannel experiences that are simple and delightful along the entire customer journey, from research to purchase to service to claims. Some established insurers have teamed up with insurtechs to capture the attention of millennials by, for example, monitoring and analyzing social media postings for life events that might trigger the need for insurance, such as the birth of a child. Other incumbents have launched their own digital brands, which promote low-cost products and superior customer experiences. Among these so-called digital attacker spin-offs are MassMutual’s Haven Life and Prudential’s LINK. Despite these early stumbles, other insurers are exploring new ways to meet consumer demand for insurance services linked to smart-home devices. Italy-based Generali has teamed up with Nest, a device company owned by Alphabet, the parent of Google.

Where do I find information about Contracting & Payer Relations?

Our security and compliance team will review your organization registration and approve or deny your ability to register applications. When you encounter an invalid token indicating a member has revoked access, you should make a reasonable attempt to handle that case making it easy for the member to understand what is happening with their data. Demographics and other administrative information about an individual or animal receiving care or other health-related services.

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates. Knowing how your costs work may be a great way to help you choose which plan might work best for you.


If they do share data with your application, they should know how long you keep it and if it is used for any other purposes. To use the UnitedHealthcare interoperability APIs a developer must register their application. An organization must register as a user by creating an OneHealthcare ID and complete the registration application through the “App Owner” section of the Vendor Portal before the ability to register applications is accessible. UnitedHealthcare Interoperability APIs are developer-friendly, standards-based APIs that enable third party application vendors to connect their application programs to access UnitedHealthcare data. Fortunately, your insurance carrier might have price transparency tools that can help you estimate what you’ll pay out of pocket, whether you get in-network care or out-of-network care.

How to Connect to Healthcare Providers and Insurers

This feature is useful for individual healthcare providers and practices that don’t display signage on the exterior of the building they occupy. The Healthcare Service resource typically describes services offered by an organization/practitioner at a location. The resource may be used to encompass a variety of services covering the entire healthcare spectrum, including promotion, prevention, diagnostics, pharmacy, hospital and ambulatory care, home care, healthcare software development long-term care, and other health-related and community services. Learn about rights and protections for consumers to end surprise bills and remove consumers from payment disagreements between their providers, health care facilities and health plans. Most often, insurance plans cover more of the cost when you see in-network providers. So your copay, coinsurance or deductible – the amount you’re responsible for paying when you get care – is usually lower.