Peter Rodes

Prealize Health participated on a panel at the Society of Actuaries (SOA) Health meeting this week, discussing how AI healthcare foundation models are used at large health plans like Premera to enhance predictive accuracy in stoploss underwriting. #AI #PredictiveAnalytics #Healthcare #stoploss

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Curious how claims data can be used for healthcare market research? It's become a powerful tool for us to help projects run smoothly. Here are three ways our VP of Research, Nick Lapolla, uses it. 👇 Check it out! 👇 #MedSurvey #ClaimsData #MarketResearch

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Six for-profit insurers now make up nearly 30% of total U.S. health spending, raising major concerns about competition and quality of #healthcare. As the #HealthInsurance landscape changes and behemoth payers continue to grow in size and scope, they have found their way into government-regulated markets where they may be overpaid for their services. A payer has also become the largest US employer of doctors. Put it all together, and you’ve got companies that are “too big to fail.” This is dangerous, as payers who continue to put their financial interests at the top of their priority list, often compromising what’s best for the patient. There are also dangers of vertical integration. Learn more: https://lnkd.in/eZAni7YY #healthcareeconomics #healthcarefinance

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Hear firsthand how Blue Shield of California is successfully using AI predictive analytics for healthcare underwriting. Plus, learn more about AI tools for healthcare underwriting and how you can put them to use. Wednesday, August 14, 1 PM PST/ 4PM EST Register now: https://lnkd.in/eykPBPKQ #Healthcare #Underwriting #PredictiveAnalytics #AI

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The Milliman LARA® (Milliman LARA) preclaim risk model was developed using predictive analytics and can be used to assist long-term care (LTC) carriers in stratifying their population to proactively manage the health and claim activity of members. LARA risk scores are a key component LTC insurer’s efforts to reduce claim cost through preventative approaches. This brochure gives examples on how customers use their LARA risk score, and answers questions such as: How often should I run LARA scores? What’s the lag in the data? What’s the match rate for your third-party data? Reach out to us if you want to know more. #ltc #preclaim #wellness Juliet Spector, Jeff Anderson, Robert Eaton, Missy Gordon, Joe Long, Alyssa Lu

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Value-based care teams modeling 2024 experience for 2025 deals were just thrown an extraordinary curveball–a significant delay in receiving claims data. How will these teams account for an almost three month gap in their data? 💫 Enter Syntax–the industry’s first and only two-sided actuarial platform for VBC. Syntax has a game-changing feature that allows users to enter itemized adjusters into a contact’s parameters. Whether based on total cost, percentage, or PMPM, itemized adjusters allow for an accounting of some of the uncertainties in modeling contracts when foundational data is dynamic and still variable (e.g., claims, eligibility, risk, and premium). Rather than waiting 9+ months for “full runout” information, actuarial and analytic teams can perform analyses on partially complete information and provide strategic business recommendations for VBC.  In addition to adjusters, users can set various terms of an arrangement and define negotiation ranges. These ranges give negotiation teams guardrails to work within–preset ranges that actuarial teams are comfortable allowing with additional financial impact review. Providers seeing their proposed contract will see these parameters as ones they can enter a counterproposal to, and the ranges give the green or yellow light to the negotiating team that the counter is in or out of range.    Syntax’s emphasis on showing the numbers and promoting transparency really shows with the parameters feature. All parameters show up in the contract summary details and each line item can be expanded to show the specifics. With features like adjusters, Syntax not only enables decision making, it also improves efficiency, promotes transparency, and reduces friction in the VBC contracting process. Message us here or contact [email protected] to find out more! #ValueBasedCare #HealthcareInnovation #TransformingHealthcare #IncentiveDesign #valuebasedcontracting #transparentcollaborationonvbc #syntaxhealth #SyntaxforVBC

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Thought provoking conversation between our CEO, Mike Desjadon and CNBC's Tyler Mathisen on The Exchange yesterday discussing the role of #AI in driving #transparency and #predictability into #healthpayment. With the technological horsepower of #AI applied to #healthpayment, its now possible to know in advance what benefits are in a plan, what these plans cover and what needs to be done to make sure payments are adjudicated correctly (the first time), and people get the care they need without the anxiety of what what might wind up in their mailbox 30 days later. This is better for everyone, provider, payer and patient alike. We're here for that future. "Payers and providers can partner together on transparency using these technologies" - Mike Desjadon https://lnkd.in/gNinRjXK

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Check out the latest blog by Joseph Valcazar! The blog analyzes the issues with using AI predictive models for insurance claims. #MedicareAdvantage #HealthcareLaw #ArtificialIntelligence #WJLTA #LawTwitter #TechLaw #legaljournal https://lnkd.in/gAxiWYtc

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Quantum Health deserves credit for initiating the practice of independent actuarial validation. The metrics consistently show Quantum Health’s navigation drives positive health outcomes and associated cost savings — from eliminating ER visits to redirecting members from choosing the wrong specialists and misguided care. Learn more about how we’ve gone #AboveandBeyondfor25Years: https://hubs.ly/Q02DMdjV0 #HealthcareNavigation

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Navigating health insurance shouldn't be a maze. Christine Cooper, CEO, aequum was featured in @MedicalEconomics discussing how Transparent Explanations of Benefits (EOBs) are key to reducing patient confusion and improving the provider experience. With the No Surprises Act and Advanced EOBs, we're moving towards clarity, enabling better patient-provider discussions and trust. Let's advocate for clearer health coverage processes and a more equitable system for all. Read the full article here: https://bit.ly/3SrwK6w #HealthInsurance #PatientCare #EOBTransparency #HealthcareTransparency #InsuranceEducation #PatientAdvocacy #MedicalBilling #HealthcareReform #HealthEquity #NoSurprisesAct #HealthcareCommunication #HealthLiteracy #PatientExperience

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𝐒𝐞𝐧𝐢𝐨𝐫 𝐇𝐞𝐚𝐥𝐭𝐡 𝐈𝐧𝐬𝐮𝐫𝐚𝐧𝐜𝐞 𝐌𝐚𝐫𝐤𝐞𝐭 𝐭𝐨 𝐒𝐞𝐞 𝐌𝐚𝐬𝐬𝐢𝐯𝐞 𝐆𝐫𝐨𝐰𝐭𝐡 𝐛𝐲 𝟐𝟎𝟑𝟎 𝗥𝗲𝗾𝘂𝗲𝘀𝘁 𝗙𝗼𝗿 𝗦𝗮𝗺𝗽𝗹𝗲 𝗟𝗶𝗻𝗸 𝗥𝗲𝗽𝗼𝗿𝘁:https://lnkd.in/g6Phtu_U Market Intellix (MI) published a new report, titled, "Senior Health Insurance Market." The report offers an extensive analysis of key growth strategies, drivers, opportunities, key segments, Porter's Five Forces analysis, and competitive landscape. This study is a helpful source of information for market players, investors, VPs, stakeholders, and new entrants to gain a thorough understanding of the industry and determine steps to be taken to gain a competitive advantage. #𝗢𝗽𝗽𝗼𝗿𝘁𝘂𝗻𝗶𝘁𝗶𝗲𝘀 • 𝗚𝗿𝗼𝘄𝗶𝗻𝗴 𝗦𝗲𝗻𝗶𝗼𝗿 𝗣𝗼𝗽𝘂𝗹𝗮𝘁𝗶𝗼𝗻: The global population of seniors is rapidly increasing, particularly in developed countries, presenting a significant opportunity for growth in the senior health insurance market. • 𝗜𝗻𝗻𝗼𝘃𝗮𝘁𝗶𝘃𝗲 𝗣𝗹𝗮𝗻 𝗢𝗳𝗳𝗲𝗿𝗶𝗻𝗴𝘀: There is an opportunity to develop innovative insurance plans that cater to the specific needs of seniors, such as long-term care insurance, critical illness coverage, and plans with wellness programs. • 𝗘𝘅𝗽𝗮𝗻𝘀𝗶𝗼𝗻 𝗶𝗻 𝗘𝗺𝗲𝗿𝗴𝗶𝗻𝗴 𝗠𝗮𝗿𝗸𝗲𝘁𝘀: Emerging markets, particularly in Asia and Latin America, are experiencing a rise in the senior population, creating opportunities for insurers to expand their offerings in these regions. • 𝗘𝗻𝗵𝗮𝗻𝗰𝗲𝗱 𝗖𝘂𝘀𝘁𝗼𝗺𝗲𝗿 𝗘𝗱𝘂𝗰𝗮𝘁𝗶𝗼𝗻: There is an opportunity to improve customer education and awareness about the benefits of different senior health insurance plans, helping seniors make informed choices. 𝗧𝗵𝗶𝘀 𝗿𝗲𝗽𝗼𝗿𝘁 𝗶𝗻𝗰𝗹𝘂𝗱𝗲𝘀 𝘁𝗵𝗲 𝗳𝗼𝗹𝗹𝗼𝘄𝗶𝗻𝗴 𝗺𝗮𝗻𝘂𝗳𝗮𝗰𝘁𝘂𝗿𝗲𝗿𝘀 • Berkshire Hathaway • Prudential plc • Zurich Insurance • China Life Insurance Co.Ltd • Allstate • AIG • Manulife Financial Advisers Pte Ltd • AXA • Allianz • Aviva • Japan Post Holdings Co., Ltd. • Generali • Chubb • Reliance Nippon Life Insurance • CPIC • Munich Re • MetLife 𝗞𝗲𝘆 𝗕𝗲𝗻𝗲𝗳𝗶𝘁𝘀: • The report provides a qualitative and quantitative analysis of the current Senior Health Insurance market trends, forecasts, and market size from 2019 to 2026 to determine new opportunities. • Porter's Five Forces analysis highlights the potency of buyers and suppliers to enable stakeholders to make strategic business decisions and determine the level of competition in the industry. • Top impacting factors & major investment pockets are highlighted in the research. • The major countries in each region are analyzed and their revenue contribution is mentioned. #SeniorHealth #HealthInsurance #Medicare #SeniorCare #ElderCare #MedicareAdvantage #MedicareSupplement #LongTermCare #SeniorLiving #RetirementPlanning #SeniorBenefits #AgingPopulation #HealthcareForSeniors #SeniorWellness #AffordableCare Market intelliX Global Trends & Analysis

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A new survey by HealthEdge finds that while most health plan members (86%) are satisfied with their insurers, a significant portion (33%) are considering switching providers next year. This highlights an opportunity for health plans to improve member engagement and loyalty. Key Findings: - The majority of members are satisfied, but competition is fierce with 92% having access to 3+ insurance options. - Members with assigned care managers report higher satisfaction, underlining the importance of personalized support. - 65% of members prefer insurers offering cutting-edge solutions and AI for personalized care experiences. - Long wait times, navigating health coverage, managing prescriptions, and finding health information remain top concerns. - Members prioritize personalized support, preventative care, and clear explanations of benefits. Learn more: https://hubs.ly/Q02CR-bf0

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