Distributed Healthcare Intelligence
Get in-network, get paid correctly, and know what changed.
Plain-language analysis of payer contracting, credentialing, managed care and reimbursement, linked to the primary sources.
Latest analysis
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Buying a Practice for Its Payer Contracts? Read the Assignment Clause First
Physician practice acquisitions are often justified by the payer contracts that come with them. Assignment and change-in-control provisions can take those contracts away, sometimes retroactively. Here is what…
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The Numbers That Drive Hospital Maternity Care Under Fee-for-Service
Under fee-for-service, hospital maternity programs are run on volume, payment per birth, efficiency, and clean billing. Here are the metrics that matter most, why C-section rates matter even…
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From HMOs to Homerooms: What Managed Care 101 Teaches Us About California’s Youth Behavioral Health Reform
HMO, PPO, EPO, capitation, value-based care — see how these managed care basics play out in real life through California’s CYBHI Fee Schedule program and its Evaluation Hub…
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Your Billing Problem Started in the Contract: What Revenue Cycle Leaders Need to Know Before a Claim Is Ever Filed
Most revenue cycle management challenges are treated as billing problems. In reality, many are contract problems — upstream issues that billing teams cannot resolve at the claims stage.…
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Doulas in Healthcare: A Smart Investment for Better Outcomes
From Ancient Wisdom to Modern Economics: The Case for Doulas in Healthcare Throughout human history, childbirth has been more than a medical procedure—it was a community event deeply…
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Business · Innovations · Leadership · Managed Care · MCO · Medical Loss Ratio · Medicare · Medicare Advantage · Payers · Providers · Startups · Value Based CareThe 2025 Healthcare Perfect Storm: How Rising Costs and Increased Scrutiny Impact Insurers
The blog post examines the health insurance industry’s challenges in 2025, highlighting rising healthcare costs, increased patient demand, and heightened government scrutiny. Insurers, particularly those focused on Medicare…
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From Startups to Shocking Bills: The Realities of Navigating Healthcare and Value-Based Care
In the latest episode of the VBCA Podcast, we explore the complexities, frustrations, and sometimes absurd realities of today’s healthcare landscape. This episode isn’t just about theory; it’s…
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Healthcare Costs and the New Population Needs Assessment
The new Population Needs Assessment requirements in California’s Population Health Management program aim to improve health outcomes while impacting healthcare costs. Initially, increased expenses from community engagement and…
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New California PNA Requirements: A Shift in Healthcare Strategy
As of 2024, California healthcare plans must submit a Population Needs Assessment every three years to enhance community engagement and address diverse health needs. This shift aims to…
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Transforming Healthcare Negotiation: The ‘Getting to Yes’ Approach
Introduction In the intricate dance of healthcare negotiations, achieving a win-win outcome can seem like a daunting task. Whether it’s negotiating agreements between health plans and providers, determining…
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Academy · Administrative Work · Business · Calculators · California · California Advancing and Innovating Medi-Cal (CalAIM) · Care Coordination · Data Tools · Finance & HR · Funding · Health Equity · KPI · Managed Care · MCO · Medicaid · Modeling · Providers · Resource · Return on Investment Calculator · ToolkitsUnlock Financial Success with CalAIM: Budget Estimator Tool for CBOs
The CalAIM Budget Estimator Tool helps CBOs navigate the financial complexities of contracting under CalAIM. It offers an Excel-based template with built-in assumptions, cost input fields, revenue customization,…
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California · California Advancing and Innovating Medi-Cal (CalAIM) · Data Tools · Databank · Value Based Care · YouthUtilizing California State Data to Enhance Care for Foster Youth
The Continuum of Care for children in out-of-home settings can be enhanced by leveraging existing data sources. California’s CDSS, DDS, DHCS, and CDE provide crucial data on community…
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Major HHS Rule Change: Is Your Healthcare Practice at Risk of Losing Medicare Payments?
The latest HHS rule targets information blocking practices in healthcare, imposing penalties for non-compliance. Healthcare providers face increased scrutiny, financial impact, and reputational risk. To comply, they must…
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Business · HMO · Innovations · Managed Care · Maternity · Maternity Kick Payments · MCO · Medicaid · PayersUnderstanding State-Level Variation in Medicaid Managed Care Maternity Kick Payments
Understanding State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care Introduction Today, we’re exploring an intriguing study on the state-level variation in supplemental maternity kick payments…
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Business · Data Tools · Databank · Policies & Procedures · Policy · Press · Resource · Value Based CareChild and Family Health Policy Insights: CCF Blog Analysis
The Center for Children and Families (CCF) at Georgetown University’s McCourt School of Public Policy offers extensive insights into health policy issues affecting children and families. The CCF…
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District of Columbia · Doula · Health Equity · Innovations · Maternity · Medicaid · Value Based CareEnhancing Maternal and Infant Health: The Role of Medicaid in Doula Services
Expanding Medicaid Coverage for Doulas: A Crucial Step for Maternal and Infant Health As the maternal and infant health crises continue to challenge the healthcare system, there is…
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California · California Advancing and Innovating Medi-Cal (CalAIM) · Care Coordination · CHIP · CMS · Justice-Involved · Medicaid · Substance Use Disorders · Value Based Care · YouthMedicaid Coverage for Incarcerated Youth: California’s Initiative
What is the Justice-Involved Initiative? The Justice-Involved Initiative is a pioneering program under California’s Medicaid reforms, specifically designed to extend Medicaid coverage to incarcerated individuals. Historically, under the…
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Business · California · California Advancing and Innovating Medi-Cal (CalAIM) · Medicaid · Population Needs Assessment (PNA) · Quality Improvement · Resource · SDoHAddressing Critical Health Needs: Partnership HealthPlan of California Strategic Response to the 2024 Population Needs Assessment
Business Brief: Addressing Critical Needs in Population Health Partnership’s membership remained relatively stable in 2023. The member redetermination process, resulting from the winding down of the COVID-19 Public…
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Classroom Attendance Calculator: A Tool for Monitoring Student Absences
Monitoring chronic absence data is essential for ensuring educators are equipped to support their students effectively. Amidst the busy school year, it can be easy to lose track…
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Business · California · California Advancing and Innovating Medi-Cal (CalAIM) · Leadership · MedicaidStrategies for Success: Navigating California’s CalAIM Program
by Ali Modaressi, California Health Report California’s ambitious journey to reshape health care through the multiyear Medi-Cal reform effort known as California Advancing and Innovating Medi-Cal (CalAIM) represents…
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Care Coordination · Data Tools · Finance & HR · Funding · Managed Care · MCO · Outcomes · Providers · Reimbursement · Resource · Return on Investment Calculator · SDoH · Startups · templates · Toolkits · Value Based Care · Value Based Operations · WorkflowsIntroducing the Care MAP Tool: A Comprehensive Guide
Introducing the Care MAP Tool, designed to support healthcare providers in managing complex care needs. This user-friendly, Excel-based tool offers a structured framework for effective care coordination, resource…
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Dashboards: Breastfeeding Intention and Duration Indicators
The Breastfeeding Intention and Duration Indicators are key measures used to track breastfeeding practices and intentions among new mothers. These indicators include plans to breastfeed exclusively or in…
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Managed Care Business Models 101 – Digital Therapeutics & Health Technology
The video titled “Managed Care Business Models 101 – Digital Therapeutics & Health Technology” on the channel Carenodes provides an in-depth discussion on healthcare business models, focusing on…
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Payer contracting
Fee schedules, assignment clauses, termination terms and negotiation.
Reimbursement & billing
Underpayments, denials, appeals and the contract terms behind them.
Managed care
HMOs, MCOs, capitation, Medicaid and Medicare Advantage.
Value-based care
Alternative payment models, ACOs and VBCA Podcast recaps.