Happy New Year! We hope that 2024 has many good things in store for everyone, especially our members, subscribers, and cherished healthcare workers!

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The payment integrity (PI) industry plays a critical role in US healthcare, ensuring that claims adjudication is accurate and that physicians and health systems are reimbursed correctly for care delivery. We estimate the $9 billion industry has grown at a 7 percent CAGR in recent years, reflecting growth in US healthcare spending and persistent complexity in billing processes. This growth has coincided with technological change, such as the rise of generative AI (gen AI), and payment model innovation, including the transition of about 60 percent of total care delivery reimbursement to value-based care (VBC) payments—shifts that have the potential to transform the PI industry. This article discusses these trends and the implications for payers, care delivery organizations, PI companies, and investors.

As we described in Part 1 of this article, specialty care providers have had limited opportunities to date for engagement in accountable care models, such as accountable care organizations (ACOs), despite their critical contributions to patient care. This is a missed opportunity for payment reform, given the growing breadth and reach of ACOs and the growing range, potential health impacts, and costs of specialty care services. Further progress is urgently needed. As the range of specialty care services continues to increase, so has the risk of fragmentation, with a large proportion of referrals never resulting in follow-ups.

Startup Guidehealth buys Arcadia’s value-based care division, plans to build out predictive, gen AI tech

Fierce Healthcare | December 22, 2023

Guidehealth, a value-based care enablement startup, bought Arcadia’s managed service organization and value-based care service division to build out its tools and service for providers. Guidehealth also is partnering with Arcadia, a healthcare technology company that provides a data platform to providers and payers, to use the company’s data analytics platform to power its newly acquired offering. Terms of the deal were not disclosed As a new player, Guidehealth has big ambitions to help providers succeed in value-based care models and improve their performance in risk-based contracts. The advancement of artificial intelligence also opens up opportunities to use technology to develop predictive analytics and insights for providers.

Medical Home Network (MHN), a leading care enablement partner for FQHCs, announced that its partners participating in the NeueHealth Premier ACO achieved $10.1 million in gross savings and a perfect 100% quality score in the 2022 performance year. This accomplishment, under the ACO Realizing Equity, Access, and Community Health (REACH) Model, involved 20 FQHCs across Ohio, Missouri, and Illinois serving approximately 10,000 Medicare beneficiaries. The success highlights the effectiveness of MHN’s collaborative approach and its commitment to empowering FQHCs in value-based care.

On occasion, we showcase one of our solution providers in a 4-5 minute interview and ask them what they bring to the VBC Community and what sets them apart. 

Today's guest:

BioReference Laboratories, Inc. is one of the largest full service specialty laboratory in the United States. With a focus on genetics, oncology, urology and women’s health, BioReference offers comprehensive test solutions and unparalleled expertise based on a 40 year legacy of proven science. Delivering reliable, convenient and innovative diagnostic solutions tailored to the specific needs of healthcare providers, patients and organizations, and with a vision to provide high quality, personalized diagnostics to all patients, BioReference is a trusted laboratory partner for value-based care organizations.

Visit the BioReference Exhibit Booth