The multimillion-dollar question is: Are you covering who you think you’re covering? This white paper gives insights into the scope of eligibility fraud among commercial managed care organizations, state employee health plans, and state and federal agencies. It also addresses why it is important to incorporate multiple, diverse data sources into your analysis to spot inconsistencies and anomalies. Lastly, read about five real-world case studies of eligibility fraud detection in action.

For provider organizations, tools that drive improved performance of legacy clinical applications as well as improve security and create efficiencies in the management of client computing are increasingly becoming critical for healthcare organizations. Desktop virtualization technology is increasingly being used by providers to realize these advantages.

Healthcare organizations are experiencing unparalleled change and are seeing both a growth in the connected-ness of care and an evolution in what is defined as an enterprise. Accountable Care organizations underscore this evolution. The Banner Health Network (BHN) was selected to participate in the Pioneer Accountable Care Organization (ACO) model, a transformative new initiative sponsored by the Centers for Medicare and Medicaid Services (CMS) Innovation Center. BHN was chosen specifically by the Innovation Center to test the effectiveness of several models of payment in helping organizations make a rapid transition to higher quality care at a lower cost to Medicare.

CIOs in healthcare delivery organizations face a changing and increasingly interdependent environment that creates new demands for integration. Many are adopting an interoperability platform that can deliver immediate and ongoing value while also supporting their strategic goals. Those strategic goals include targeting readmission rates as a source of cost reduction and implementing new value-based reimbursement models such as Accountable Care and Medical Home Initiatives.

Medicare Advantage (MA) plans are private health plans that have contracted with <a href="/directory/medicare" target="_blank" class="directory-item-link">Medicare</a> to receive a fixed monthly fee in exchange for providing comprehensive healthcare to plan members. In order to provide appropriate care to beneficiaries with varying medical conditions, plans are paid according to the Risk Adjustment Factor (RAF) score of each patient. Insufficient documentation of chronic conditions can be an obstacle to MA reimbursement. However, even when a condition has been properly documented by the provider, it is often not coded and submitted to Medicare. Read this white paper to learn how to take the complexity out of MA reimbursement.