The ups and downs of payor coding practices: how upcoding and downcoding both undermine trust
Payors are inflating patient risk scores to boost their payments from federal programs while adjusting provider claims to pay less.
Q3 2025 earnings recap: higher revenue, elevated costs, and payors prepping to pivot
Having closely followed the Q3 2025 earnings calls from key payors, Kevin Thilborger covers key trends and takeaways.
Exploring Power Imbalances in Managed Care
This piece by was originally published in First Report Managed Care The US health care system is undeniably built around the needs of private insurance companies. The market dominance of a few for-profit companies gives them significant control over health coverage for millions of Americans and substantial influence over the policies that govern health care. […]
Rethinking revenue: why health systems need a bigger pie, not just a better slice
Health systems can’t rely on collections alone. See how rethinking your managed care revenue strategy can expand margins, strengthen contracts, and drive sustainable health system revenue growth.
More than halfway through 2025, how good were our predictions?
At the start of 2025 we published our predictions for six key areas to watch in managed care. More than halfway through the year, we check in to see how we did.
Months later: Have health insurers delivered on their prior auth promises?
Health insurance companies pledge prior authorization reform, yet providers face ongoing delays and distrust, highlighting the gap between promises and reality.
Learn from North Carolina’s model before other states follow suit
North Carolina is rolling out a “no cost” surgical benefit this fall. Here’s what providers in and out of North Carolina need to know.
The Pivot: The (im)perfect storm hospitals face in 2026 and 2027
In the next 18-24 months, headwinds facing healthcare providers will become a full-blown hurricane. Unlock CEO, Brandon Edwards, explores factors that must be addressed as providers prepare to weather the coming storm.
What the heck is going on with MLR and the health insurance business?
Unless patients suddenly stop incurring health insurance claims, there’s only one place left for payors to go to get control of rising medical loss ratios: providers. By understanding this, providers can better prepare for what’s ahead.