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Waste Accounts for 25% of Health Care Spending. Addressing Fraud and Abuse Can Help.

It already hurts to hear that the United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product and more than $10,000 per individual.

A report published last week in The Journal of the American Medical Association makes those numbers even more painful as it reveals the estimated cost of waste in the United States ranges from $760 billion to $935 billion, accounting for approximately 25% of total health care spending. This amount exceeds national military spending, as well as total primary and secondary education spending.

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Go Beyond the Cloud with Rachel Wang

Meet Rachel Wang, a data scientist at Softheon.

Born in the province of Shendong in northeastern China, Rachel came to the United States to pursue education and professional development. She already studied mathematics and economics at a college in China but sought further mastery in mathematics. Thinking mathematically comes easily to her and she enjoys how “every problem is a math problem.”

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Don’t Leave Money on the Table: Five Steps to Addressing SDOH

Softheon
October 3, 2019
Affordable Care Act / healthcare payers / Providers
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PricewaterhouseCoopers Health Research Institute recently released their new report: “Action Required: The Urgency of Addressing Social Determinants of Health.” Anyone in health care eager to save on costs and create efficient medical interventions should review this report. This piece provides a review of report, highlighting the five steps PwC recommends taking to lead in social determinants of health (SDOH).

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Let the Data Speak for Itself: The Relationship Between Work and Health

Softheon
September 30, 2019
Medicaid
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Both before and after the Centers for Medicare and Medicaid Services’ (CMS) policy reversal on work requirements, stakeholders have debated whether employment leads to improved health outcomes. CMS and states that have implemented or are trying to implement work requirements argue they do, while others disagree. The recent research of the Kaiser Family Foundation (KFF), a nonpartisan organization, illuminates what the data says on the relationship between work and health. This piece provides a recap of KFF’s findings.

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Rising Uninsured Rate and How States Can Respond

Softheon
September 24, 2019
Affordable Care Act / Medicaid / State & Federal Insurance Exchanges
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Earlier this month, many noted the Census Bureau’s report of the increasing number of uninsured Americans. 8.5 percent, about 27.5 million people, lacked health insurance in 2018, up from 7.9 percent in 2017. It was the first year-to-year increase in the uninsured rate since the Affordable Care Act (ACA) in 2010.

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CMS Continues Mission on Integrity with Affiliations Final Rule

Last week, the owner and CEO of Video Doctor Network pled guilty to a $424 million Medicare kickback scheme. He admitted to receiving kickbacks and bribes from recruiters, pharmacies and brace suppliers in turn for arranging doctors to order medically unnecessary orthotic braces for Medicare beneficiaries. As reported by Healthcare Dive, this is one of the largest schemes to defraud Medicare ever investigated by the Federal Bureau of Investigation (FBI) and the Health and Human Services (HHS) Office of the Inspector General and prosecuted by the Department of Justice.

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Product Talk: Enhanced Direct Enrollment

Softheon’s private-label enrollment solution, Enhanced Direct Enrollment-as-a-Service (EDE) offers a unified enrollment experience and an updated, easy-to-use portal for Marketplace members. Now available to any health plan engaged in the ACA Marketplace once it informs CMS that it is partnering with Softheon as an EDE vendor, Softheon EDE uses a series of Centers for Medicare and Medicaid Services-based (CMS) application program interfaces (APIs) to process eligibility and changes behind the scenes. In this interview, we spoke with Min Kyu Han, one of EDE’s product owners.

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HMA Conference Recap

Softheon
September 11, 2019
Affordable Care Act / Conferences / Medicaid
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The Health Management Associates (HMA) conference brought together hundreds of industry executives from health plans, governments and community-based organizations serving Medicaid, Medicare and vulnerable populations. Set in Chicago, Illinois, the conference shed a light on the challenges and opportunities for health care entities in the publicly sponsored health care arena.

In case you were not able to attend, here is a recap of the key topics discussed:

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Maine the Latest to Join the SBM Groundswell

Softheon
September 9, 2019
Affordable Care Act / Medicaid / State & Federal Insurance Exchanges
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To improve the state’s ability to fund education and outreach, Maine Governor Janet Mills submitted a letter of intent last week to the Centers for Medicare and Medicaid Services (CMS) to become a state-based marketplace on the federal platform (SBM-FP).

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North Carolina’s HHS-backed Health Care Venture

Softheon
August 30, 2019
Affordable Care Act / healthcare payers / Providers
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What if instead of paying doctors based on their number of visits with patients we paid them based on how well they improved the health of their patient? Say how well they controlled a diabetic patient’s blood sugar or a heart attack patient’s cholesterol?

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