In early April, the Centers for Medicare and Medicaid Services (CMS) finalized the 2025 Medicare Advantage Rule. This legislation also included changes to Medicare Part D, which covers prescription medications. Many health care organizations were expecting updates...
Medicare Advantage Spending Surge: What the 2023 Data Reveals & What Your Health Plan Needs to Know
A review of last year’s data shows a spike in service utilization for members with Medicare Advantage (MA) plans in 2023. This information came from an AHIP survey, which found that total medical expenses in the fourth quarter were up 8.1% compared to the same time in...
Inaccurate Reports of Vaping History Impacting Health Insurance Premiums
Vaping has been highly criticized due to its negative health effects, especially as the Food and Drug Administration (FDA) has cracked down on banning flavored e-cigarette products. As vaping use has increased among adolescents and young adults over the past decade,...
Proposed Federal Legislation Intended to Expedite Prior Authorization Approval Process
Recent legislation proposed by the Biden administration aims to address member dissatisfaction with insurance approval wait times. If passed, this rule will apply to prior authorization requests through government insurance plans and could go into effect starting in...
Safeguard Your Pharmacy Reimbursement and Avoid Audits
With ongoing medication shortages and astronomical costs for specialty drugs, nearly all members can benefit from medication savings. Furthermore, managing costs helps payers keep reimbursement rates steady for their partners. TOG has identified several tools that can...
Exploring the Untapped Potential of Effective Provider Network Management for Health Insurance Executives
Navigating the intricate dance of network adequacy, provider relationships, and regulatory compliance can feel like a continuous tightrope walk. These responsibilities are crucial for member satisfaction and organizational health, yet they often need to be juggled...
Prepare for Medicaid Access Changes: What Your Health Plans Need to Know Now
Network inadequacy can create a big headache for health plans, so payers should give special attention to any legislative changes (either proposed or finalized) to these policies. One potential change is related to Medicaid and managed care access standards. Since the...
Do You Value Predictable ROI From Your Provider Network?
TOG Launches Medical Economics Division Optimizing Payer Profit Margins TOG is now the only health care provider network builder with a medical economics division that supports the full network operations life cycle. The division was added to help payers make sound...
Record-Breaking ACA Enrollment: What It Means for Your Health Plan
Estimated Read Time: 3 Minutes The Affordable Care Act has hit a historic milestone! Over 20 million Americans are now enrolled in individual marketplace plans – nearly 6% of the population. In 2023, there were 16.3 million individuals enrolled in these plans, which...
Infectious Disease Cases are Rising: How Can Your Health Care Provider Network Act as a Buffer?
Estimated Read Time: 5 Minutes Learn how your health care provider network can: Identify community hot spots & engage vulnerable populations. Craft engaging educational content for optimal reach & impact. Boost patient engagement & safety through testing...