Author: LBodnarchuk

The Medicare Advantage Reset: What Health Plans Must Do Next

Written by LBodnarchuk on . Posted in Insights.

Medicare Advantage (MA), since its inception, has been on a meteoric rise. With more than half of all  eligible seniors enrolled in the program, it remains a popular choice for consumers. However, the convergence of several factors over the past few years has marked a turning point for the program as we know it. Driven primarily by the COVID pandemic reset, rising utilization, increased regulatory scrutiny and an overinflated market, leading payors are rethinking previous models for success. What we’re seeing now are plans exiting key markets and launching resets of their own, including rethinking benefit designs, reducing administrative costs and considering the role of artificial intelligence in the context of managed cares, “new normal”. What worked yesterday, most certainly, will not work for tomorrow.

To be clear, this is not the end of Medicare Advantage; it is a paradigm shift. Those plans that seize this opportunity to take a hard look in the mirror and prepare themselves for the Medicare Advantage of tomorrow will most certainly be long term winners.

At ProspHire, we see four priorities that will define success for Medicare Advantage organizations in 2025 and beyond:

1. Define Your Goal, Then Recalibrate Portfolios, Products and Markets

The first step in navigating this reset is a strategic one, not an operational one. Too often, plans leap into tactical fixes without clarifying who they want to be. The fundamental question is: what is your goal?

  • Do you want to be a growth leader, capturing market share and aggressively expanding into new geographies?
  • Do you want to be a profitability leader, focusing on margin discipline and sustainable operations?
  • Do you want to specialize in specific populations, such as dual eligibles or chronic condition cohorts?

Once that strategic identity is clear, portfolios and products must be recalibrated accordingly. The right benefits, the right markets and the right member segments should all ladder up to that core purpose. Without alignment, plans risk chasing growth in areas where the economics don’t work or overinvesting in products that don’t match their long-term strategy.

2. Revitalize Member Engagement

Action areas include:

  • Proactive and personalized outreach, leveraging data to anticipate member needs.
  • Intuitive tools and digital navigation that reduce confusion.
  • A true focus on experience equity — meeting members where they are, across geography, culture and socioeconomic status.

Another important note looming in the MA space is that the first Gen X’er will be Medicare eligible in 2030, which is less than 5 years away. This represents an entirely new consumer segment with new expectations that plans will need to meet.

3. Invest in Technology and Infrastructure for Tomorrow

Success in MA is massively dependent on data: how it’s acquired, how it’s managed and how it’s used to make decisions. Many health plans today are still operating with fragmented systems, outdated analytics and cumbersome integrations. That is no longer sustainable.

The reset is the right moment to make serious infrastructure investments:

  • Build robust IT and analytics capabilities that support real-time decision-making.
  • Prepare for digital quality measurement and data submission in an ECDS/FHIR world.
  • Reevaluate vendor relationships to ensure each partnership contributes to a smarter, more integrated tech stack.

The message is simple: technology is a competitive differentiator and plans that invest wisely now will be positioned to outpace competitors for the next decade.

4. Optimize Revenue Drivers: Stars, Quality and Risk

While the regulatory environment continues to shift, the core revenue levers of Medicare Advantage (Stars, quality and risk adjustment) remain central to financial sustainability. Yet these are often not given the investments required or siloed into business-as-usual functions rather than treated with the strategic importance they deserve.

Health plans must:

  • Prioritize Stars improvement strategies that align with member experience, CAHPS and clinical outcomes.
  • Consider new, innovative care delivery models, including PACE, neighborhood-driven clinical care delivery and other models to deliver care that members need.
  • Tighten risk adjustment accuracy to avoid over- or under-coding exposures in a stricter audit environment.
  • Treat quality not as an end but as a margin enabler, directly tied to reimbursement and member retention.

Even amid change, this truth remains: optimizing Stars, quality and risk is not optional. It is a foundational pillar of Medicare Advantage success.

What’s Next? Embrace the Reset and Seize the Opportunity

At ProspHire, we believe this is a moment for reinvention and a time for plans to confront hard questions, make bold choices and position themselves for long-term success. The Medicare Advantage of tomorrow will not look like yesterday’s version and that is precisely what makes this reset an opportunity worth seizing.

AI is Reshaping Healthcare: Here’s Where Experts See the Greatest Value

Written by LBodnarchuk on . Posted in Insights.

Artificial Intelligence (AI) is no longer a futuristic concept in healthcare — it’s here and it’s making waves across multiple facets of the industry. From streamlining operations to enhancing patient care, AI promises to transform how health plans, providers and patients interact with the healthcare system.

Where Will AI Deliver the Most Value in Healthcare?

In September, we asked our LinkedIn community: “AI in Healthcare: Where Will It Deliver the Most Value?” and the results offer some intriguing insights.

Poll Results:

  • Fraud Detection – 44%
  • Revenue Cycle Management – 25%
  • Clinical Decision Support – 25%
  • Patient Engagement – 6%

What These Results Tell Us:

  • Fraud Detection Leads the Way: Nearly half of respondents see AI’s biggest impact in combating fraud. This aligns with the growing need for healthcare organizations to protect revenue streams and reduce financial risk. AI-powered algorithms can identify unusual patterns in claims data, flagging potential fraud faster and more accurately than traditional methods.
  • Revenue Cycle Management & Clinical Decision Support: Both tied at 25%, highlighting AI’s potential to optimize billing, coding and decision-making processes. AI can help providers make better clinical choices, reduce errors and ensure appropriate reimbursement.
  • Patient Engagement Trails Behind: Only 6% of votes pointed to patient engagement, signaling that while AI-driven apps and chatbots are growing, there’s still untapped potential in improving patient interactions and experiences.

Final Thoughts on AI in Healthcare

The results demonstrate that healthcare professionals are seeing AI’s immediate value in operational efficiency and financial protection. While patient engagement remains a key area for innovation, the focus today is on ensuring accuracy, security and smart decision-making across the healthcare ecosystem.

At ProspHire, we help healthcare organizations harness the power of AI responsibly, targeting the areas that provide the highest return on investment and measurable outcomes.

CMS Introduces New Reporting Requirements to Strengthen Utilization Management Oversight

Written by LBodnarchuk on . Posted in Insights.

On June 9th, CMS published a draft of new regulatory reporting requirements1 that enhance oversight of initial organization determinations (ODs) and reconsiderations.

This follows the direction set in the 2026 Medicare Advantage Final Rule, which introduced regulations to reinforce prior authorization and utilization management (UM) safeguards. The proposed reporting requirements strengthen CMS’s commitment to taking meaningful action to control inappropriate prior authorization and UM practices that create unnecessary barriers to care access. This new administration has made it abundantly clear that wasteful spend, fraud, abuse and inefficiency will not be tolerated.

Reporting Requirement Details

These new reporting requirements will require plans to submit significantly more detailed information on a quarterly basis than what is currently required by CMS, moving from the existing aggregate reporting of cumulative totals and outcome categories (fully favorable, dismissed, adverse, etc.) to comprehensive details on every individual organizational determination and reconsideration they receive.

CMS requires that healthcare plans now have to submit information that covers certain areas.

Actions for Medicare Advantage Plans

These new requirements could cause operational and compliance challenges for Medicare Advantage plans. The granular requirements will provide CMS with a new level of visibility into plan decision-making processes to identify inappropriate denials, processing delays and inconsistent application of coverage criteria. Given this enhanced level of oversight, it’s essential that plans develop robust capabilities to produce the required reporting elements accurately and on time, with plans maintaining high denial rates likely facing intensified regulatory scrutiny.

How to Prepare for the CMS Changes

To prepare for these requirements, plans should:

  • Review Internal Documentation: Conduct a review of current policies and procedures to ensure that they capture OD and reconsideration compliance requirements
  • Establish Quality Validations: Create monitoring processes to track key metrics such as processing timelines and outcomes, denial and adverse decision rates and validity to curb any issues that would raise concern to CMS
  • Evaluate Reporting Capabilities: Ensure your OD and reconsideration systems and infrastructure are capable of capturing, storing and reporting detailed case-level data
  • Produce Test Reporting: Generating example/test reports sooner rather than later will help plans achieve accuracy in reporting details to ensure CMS timelines are met for report submission requirements and level of accuracy needed

Plans that proactively address these operational and regulatory changes now will be better positioned to demonstrate compliant utilization management practices and avoid potential regulatory consequences such as corrective action plans and financial penalties.

How ProspHire Can Help

Do you need support navigating these new regulatory requirements? ProspHire can help with a comprehensive compliance readiness review to ensure your organization is prepared. Let’s have a conversation.

  1. HPMS Memo released by CMS on 06/09/2025, “Technical Specifications for the Service Level Data Collection for Initial Determinations and Appeals (CMS-10905, OMB: 0938-New)” ↩︎

Understanding CMS’s Proposed Changes for Play Year 2026: Key Insights from the Draft 2025 Call Letter

Written by LBodnarchuk on . Posted in Insights.

In the newly released Draft 2025 Call Letter for the Quality Rating System (QRS) and Qualified Health Plan (QHP) Enrollee Experience Survey, CMS has outlined proposed changes for Play Year 2026 and beyond. Here’s what you need to know.

What’s Changing in the 2025 QRS Draft?

A quick look at CMS’s key proposed updates for Play Year 2026:

CMS’s key proposed updates for Play Year 2026.

Key Proposed Changes

1. Measure Removals

  • CMS proposes removing the International Normalized Ratio Monitoring for Individuals on Warfarin (INR) and Annual Monitoring for Persons on Long-Term Opioid Therapy (AMO) measures.​
  • The Social Need Screening and Intervention (SNS-E) measure is also proposed for removal.

Impacts:

  • INR: Current clinical guidelines strongly recommend the use of Direct-Acting-Anticoagulants (DOACs) over Warfarin because DOACs demonstrate comparable efficacy for several indications and do not need frequent international normalized ratio monitoring and dietary restrictions. Since the emergence of DOACs in the last two decades, the utilization of Warfarin has steadily decreased across demographics (Navar et. al., JAHA 2022).
  • However, studies and previous years’ QRS results indicate that despite the decreasing trend in Warfarin utilization, many providers continue to prescribe the drug.  Removal of the INR measure, therefore, may impact patient safety for individuals that are still on said drug regimens. QRS results for 2024 indicate that 20,000 beneficiaries across the country received Warfarin therapy and 48% of plans qualified for scoring for this measure. Given these numbers, we agree with the proposal to remove the measure from a quality benchmarking standpoint. However, we urge health plans with members on Warfarin therapy to rollout provider steering strategies to facilitate adoption of DOACs in accordance with clinical best practices.
  • AMO: According to the 2024 QRS data, 114K beneficiaries received long-term opioid therapy across the country and 76% of plans were scored for this measure. Recent studies have indicated a decrease in opioid prescription for treatment of chronic non-cancer pain, down to 30% in 2019 (Bandara et. al., Plos One, 2019). However, given the significant risks associated with long-term opioid use and that the majority of plans continue to score for this measure, we recommend delaying the exclusion of this measure. This would allow time for more current assessments of clinical trends in long-term opioid utilization and further decrease in utilization among beneficiaries.
  • SNS-E: Health plans may inadvertently overlook critical non-medical factors that significantly impact patient health, such as housing instability, food insecurity and access to transportation. Without this measure, health plans may also have fewer incentives to develop and implement targeted programs that address these social determinants of health. This could potentially exacerbate existing health disparities and widen inequities in care, particularly among vulnerable populations who are already at a higher risk for poor health outcomes.

2. Measure Addition:

  • A new “Enrollee Experience with Cost” measure is proposed to assess enrollees’ perspectives on healthcare costs.​

Impact:

  • The introduction of the “Enrollee Experience with Cost” measure could drive health plans to focus more on affordability, transparency and consumer satisfaction. It will likely influence plan ratings, consumer choices and health equity initiatives while pushing insurers to improve cost control mechanisms. The measure has the potential to create a more transparent, consumer-centric healthcare environment where cost is a key factor in both plan selection and patient satisfaction.

3. Measure Transition:

  • The existing Controlling High Blood Pressure (CBP) measure may transition to the Blood Pressure Control for Patients with Hypertension (BPC-E) measure.​

Impact:

  • This change may enhance health equity by targeting vulnerable populations, promoting a more patient-centered approach and encourage long-term, comprehensive care. Health plans and providers will need to adjust their practices and reporting systems to align with this more focused measure, which could lead to better quality ratings in the QRS and improved care for high-risk individuals

4. Measure Refinements:

  • Proposed refinements include updates to the Breast Cancer Screening (BCS-E) and Adult Immunization Status (AIS-E) measures.​

Impact

  • These updates may enhance preventative care efforts by expanding the eligible population and addressing age-related disparities. Lowering the BCS-E screening age to 40 encourages earlier detection for younger women, who historically have lower screening rates. Health plans and providers will need to implement age-targeted outreach, adjust clinical workflows and enhance provider communications to support this change. Stratified reporting by age bands may also help to identify gaps in care and inform quality improvement strategies.
  • The additional indicator for Hepatitis B vaccine in adults 19-59 supports increased vaccine uptake and aligns with NCQA. However, capturing data from sources such as pharmacies and public clinics may present interoperability challenges. Health plans may need to strengthen data-sharing capabilities and implement targeted member and provider engagement strategies to raise awareness and improve vaccination rates.

Electronic Clinical Data System (ECDS) Reporting Expansion:

  • CMS plans to transition certain measures, such as Cervical Cancer Screening (CCS-E), Immunizations for Adolescents (IMA-E) and Childhood Immunization Status (CIS-E), to ECDS-only reporting.​

Impact:

  • The shift to ECDS-only reporting for Cervical Cancer Screening, Immunizations for Adolescents, Childhood Immunization Status and Blood Pressure Control could accelerate the adoption of more integrated, data-driven care. Health plans may be pushed to strengthen partnerships with providers and invest in better clinical data exchange to ensure accurate reporting. This move could improve care visibility and lead to more timely interventions, but it may also challenge plans with limited access to EHR or HIE data. Ultimately, this transition supports a more holistic and proactive approach to quality measurement, but readiness and infrastructure will play a key role in performance success.

QHP Enrollee Survey Sample Frame Revisions:

  • Revisions are proposed for the QHP Enrollee Survey sample frame variables to enhance data accuracy.​

Impact:

  • The revisions to the QHP Enrollee Survey may improve the comparability of QHPs, identify areas for improvement and promote better health equity by ensuring that underserved populations are adequately represented. Adjustments to data collection and reporting processes may be necessary, while consumers could benefit from more trustworthy quality ratings to guide their healthcare decisions.

How ProspHire Can Help

Our team at ProspHire is closely tracking these developments to help you stay compliant, competitive and ahead of industry shifts.

Want to talk through how these changes may impact your quality strategy or operational planning? We’re here to help, so contact us today.

Q&A with ProspHire’s Caitlin Nicklow on Project Delivery

Written by LBodnarchuk on . Posted in Insights, Insights on Healthcare Project Delivery.

Healthcare is an industry that touches every one of our lives yet few are privy to the behind-the-scenes work that keeps the wheels turning. Healthcare organizations must balance servicing their member’s needs today while also planning for their needs 10 years from now. ProspHire’s Caitlin Nicklow sheds light on the rising demand for project delivery and how successful execution can position healthcare organizations for both short and long terms success.

Can you provide an overview of ProspHire’s Project Delivery practice and its role within healthcare consulting? 

ProspHire’s Delivery Practice first and foremost is focused on the desired outcomes of our clients and providing the right level of expertise in terms of talent and experience. When a client engages ProspHire, we seek to understand their most pressing needs and then design a tailored support solution. ProspHire specializes in a variety of types of projects including Large Scale System Implementations, Health Plan Integrations, Establishing/Enhancing EPMO capabilities, as well as Program and Project Management. Our team consists of certified Project Management Professionals (PMP), Six Sigma Green Belt Certified Scrum Masters and Certified Product Managers who offer industry expertise in the payer and provider sectors.  

ProspHire supports several project delivery projects including health plan integrations, project management and more

What are some key challenges that healthcare organizations typically face when it comes to project delivery and how does ProspHire address these challenges?  

The major challenges healthcare organizations must consider when approaching project delivery are time, resources, and cost. Many projects are time bound by operational urgencies, compliance mandates, and other factors. Project delivery also requires time from the same resources that are already fully allocated to a day job. Many organizations manage these two constraints at the expense of the overall budget. Our goal is to provide our clients with relief. We do this by supplementing their teams with highly skilled resources to give them time back in their day while keeping projects on time and on budget. We also use our decade of industry expertise to find efficiencies and streamline project delivery.

Could you share a success story that highlights the impact of the Project Delivery practice on a healthcare client’s operations or outcomes?  

One of our clients is currently going through rapid growth and transformation. With that comes the need to connect business and technical process/decision making and manage decisions/dependencies. The client engaged ProspHire to manage several of those programs. We were able to utilize our strong execution skills, industry and process knowledge and our strong relationships to act as an extension of our stakeholder, identify risk, and implement mitigation plans to keep the project on track. At the end of the project, our client stakeholders remarked that they can’t tell the difference between our ProspHire teams and their full-time employees due to our seamless integration into their work and alignment with their organizational mission.  

In the rapidly evolving healthcare landscape, how does ProspHire stay ahead of the curve in terms of project management methodologies and industry best practices?  

ProspHire practitioners are experts in operating in a variety of different project management methodologies including agile, hybrid, and waterfall approaches.  We also take the time to understand the methodologies utilized by our clients. ProspHire collaborates with some of the largest healthcare organizations in the country and that entails many customized ways to deliver projects. Several factors contribute to selecting the right delivery methodology for a specific client and initiative, including understanding the organization’s current capabilities, the evolving implementation journey, complexity, scale, speed and specific goals of the company. To keep up with the ever-changing delivery landscape, ProspHire invests in our employees through continuing education and certifications through ProspHire University (PMP, Agile, etc.). 

What role does technology play in optimizing project delivery within healthcare organizations and how does ProspHire leverage technology in its consulting services? 

Technology always plays a critical role in project delivery. From a macro level, this starts with an organization’s ability to manage strategic portfolios of projects that align to the long-term vision and goals. It’s key to keeping leadership informed on desired outcomes by continually tracking the demand, the portfolios, the capacity to support them as well as accurate KPIs to overall performance. At the project level, we utilize various Project Portfolio Management (PPM) applications to manage project status, risk mitigation strategies and financials for our clients.  

Collaboration is crucial in project delivery. How does ProspHire develop collaboration among cross-functional teams within healthcare organizations to ensure successful project outcomes? 

Working in any sized organization, project execution rarely impacts a single business area and with that highlights the importance of building trust and relationships. It is critical to understand how people like to communicate and their leadership styles and set clear expectations for the team’s relationship. Projects are not all filled with good news as dependencies, resource constraints and competing priorities also become a factor. Setting clear expectations, communicating frequently and building a strong relationship up-front goes a long way to staying aligned and gaining respect with our clients.  

Healthcare projects often involve complex regulatory and compliance requirements. How does ProspHire ensure that its clients navigate these challenges effectively?   

Regulatory and compliance projects always start with an understanding of the requirements and how these requirements impact the current processes, workflow and technology. Even the smallest change impacts the business and with the heightened compliance or regulatory impact it’s critically important to establish strong collaborative governance models that hold people accountable, communicate an accurate status, empower the right people to make decisions and share a transparent risk assessment with clear mitigation strategies.  

Can you share some insights into the skills and expertise that your Project Delivery practice team brings to the table to make a difference in healthcare projects?  

At ProspHire, our practitioners have experience in Payor, Provider, Dental and even post-acute projects. That experience helps us work side by side with our business, technical and regulatory compliance stakeholders to inform decision making, provide recommendations and ultimately give our clients time back to focus on the business. In no way are we replacing our stakeholders but rather allowing our experience to build the trust they seek when delivering projects. Our clients seek a partner with a proven reputation for delivering complex and priority initiatives, effectively planning and managing progress and risks and understanding implications to processes, technology and regulatory demands.   

Risk management is vital in any industry. How does the PMO identify and mitigate potential risks that could impact the success of healthcare consulting projects? 

Risk management and communication are critical to managing a program/project and building trust with your clients. Risk is going to happen on every project and how that is documented and communicated is vitally important. Risk is not about calling teams or individuals out but rather a way to communicate what is causing the risk, the impact and the mitigation options to manage the risk. By not sharing or communicating risks, it is likely going to grow into something more unmanageable thus further impacting the project and resources supporting the desired outcome. At ProspHire, we run towards the risk and aim to understand the root cause, the impact of the project and defining a clear strategy for managing the risk.

New trends and innovations impacting project delivery in healthcare

Looking ahead, what trends and innovations do you foresee shaping the future of project delivery in healthcare and how is ProspHire preparing to adapt to these changes?

Digital transformation, data analytics and AI and process automation are all new trends and innovations that are now impacting project delivery in healthcare. It is important that we understand the needs and capabilities of every organization we work with to gauge their ability to evolve. And as important in understanding the technology, equal importance is understanding how operational processes may need to be examined and redesigned to complement and gain further efficiencies and quality gains that technology brings. At ProspHire, we are continuously training and upskilling our practitioners in emerging technologies and healthcare trends and regulations. We collaborate with technology companies and healthcare providers to develop innovative solutions that help to stay current with industry developments and we tailor solutions to the unique needs and challenges of every healthcare client.

ProspHire will work with you to understand your unique circumstances and identify the best methods to achieve your goals. Connect with us today to learn more.

Scaling or Optimizing Your Medicaid Operations? We’ve Got You Covered

Written by LBodnarchuk on . Posted in Insights, Medicaid.

There is a saying in the Medicaid community of “if you know Medicaid in one state, you know Medicaid in one state” given the variation in program eligibility, services and operations across states. While this remains true, there are fundamentals in Medicaid services, quality performance and operations that remain the same nationally. 

As health plans seek to differentiate themselves in the market and deliver a member-first program, ProspHire supports health plans in establishing a strategic roadmap that integrates organizational goals and unique regional membership needs. ProspHire is dedicated to a regional approach to product development, quality programs, and member engagement. Demonstrating this commitment, ProspHire leverages and promotes the use of social determinant of health and other publicly available data sources to develop data-driven strategies and identify key steppingstones to appropriately address unique health plan membership needs. Check out our data dashboard! 

Medicaid plans seeking to outperform will need to look beyond their bottom line and focus on the successful delivery of care and resulting outcomes for their membership. ProspHire collaborates with health plans to bring vision and strategy to execution and reality as a partner to your organization and your community. 

The intent to award Medicaid contracts presents both opportunities and challenges for health plans. Whether you are an incumbent plan seeking to optimize performance or a new entrant preparing for go-live, ProspHire specializes in providing strategic support to drive operational success.

Opportunities in Focus

  • Operational Readiness
    • Develop and execute a comprehensive implementation plan to meet state requirements. Establish effective workflows, IT system integration and operational policies.
    • Conduct readiness assessments to mitigate risks prior to go-live.
  • Provider Network Expansion & Management
    • Assess and expand provider networks to meet state adequacy standards.Implement contracting strategies to enhance access to care and quality measure performance.
    • Improve provider relations and streamline credentialing processes.
  • Regulatory Compliance
    • Ensure alignment with state Medicaid regulations and reporting requirements. Conduct compliance audits and gap analyses.
    • Develop policies and procedures to maintain ongoing compliance.
  • Quality Programs, Performance & Addressing Health Disparities
    • Optimize HEDIS and Medicaid quality measures to improve performance. Implement care management programs to enhance member health outcomes. Align quality initiatives with state and federal benchmarks. Implement social determinants of health (SDOH) strategies. Develop community engagement initiatives to improve equity in care.
    • Leverage data analytics to identify and address disparities.
  • Member Experience
    • Improve CAHPS and member satisfaction scores through targeted interventions.
    • Develop data-driven member engagement strategies.
  • Administrative Cost Savings
    • Identify cost-containment opportunities to maximize efficiency. Streamline operations to reduce administrative burden through systems integration, process automation and strategic workflow optimization.
    • Leverage technology to enhance claims processing, contracting and other productive repetitive activities.

ProspHire Can Help

By partnering with us, health plans can confidently navigate the complexities of Medicaid implementation and achieve operational excellence. Contact us today to learn more about how we can support your success.

Soaring to New Health: Healthcare Uncovered Series

Written by LBodnarchuk on . Posted in Blog.

Welcome to the Healthcare Uncovered Podcast Series– your front-row seat to the future of healthcare. In this exclusive blog series, we spotlight expert insights and real-world strategies from ProspHire’s Soaring to New Health podcast. Each episode takes a deep dive into a distinct area of the healthcare ecosystem, from the rise of cloud-based dental software to unlocking Medicare Stars success, optimizing Medicaid and navigating the ever-changing ACA marketplace. Whether you’re a provider, payer or industry leader, these conversations are designed to inform, inspire and empower you to drive meaningful change. Need a quick overview? Click on the series highlights infographic to the right.

Explore the full series below and uncover the innovation shaping healthcare today.

The Modern Dental Practice – Software to Believe In

Revolutionizing Dental Care Through Technology

The dental industry is evolving, and cloud-based solutions are leading the charge. In this episode, we dive into the future of dental practice management software and how innovations are helping dental organizations scale, optimize operations, and improve patient care.

Our experts discuss the impact of cloud technology, how it enhances workflow efficiency and why leading dental practices are making the switch from legacy systems. If you’re looking to streamline practice management and improve operational outcomes, this episode is a must-listen!

Tune in now to discover how technology is transforming dental care!

Listen Here

Stars Performance – Unlocking 5-Star Success

How Health Plans Can Improve Quality and Performance

Achieving a 5-Star rating is no small feat, but it’s essential for health plans aiming to deliver high-quality care while maximizing reimbursement. In this episode, we break down the critical factors behind Stars success, from improving member engagement to optimizing HEDIS and CAHPS performance.

Our experts share best practices for navigating CMS guidelines, addressing key challenges in Stars improvement and driving meaningful quality outcomes. If you’re looking to enhance your health plan’s Star rating, this conversation provides actionable insights you won’t want to miss.

Listen now and take your Stars strategy to the next level!

Listen Here

Medicaid Strategy – Enhancing Access and Efficiency

Innovative Approaches to Medicaid Optimization

Medicaid plays a crucial role in providing healthcare access but navigating its complexities requires strategic expertise. In this episode, we explore how health plans and providers can enhance Medicaid quality, control costs and improve member experiences.

We cover key topics like Medicaid HEDIS optimization, addressing health disparities and integrating new technologies to streamline processes. With rising demands on Medicaid programs, this discussion is essential for healthcare leaders looking to drive innovation and efficiency in Medicaid services.

Tune in to explore cutting-edge strategies for Medicaid success!

Listen Here

The ACA Marketplace – What’s Next?

Navigating Risk Adjustment and Market Trends

The Affordable Care Act (ACA) marketplace continues to evolve and insurers must stay ahead of changing regulations, risk adjustment policies and enrollment trends. This episode takes a deep dive into the challenges and opportunities in the ACA landscape.

Our discussion highlights risk adjustment transfer payments, how insurers can optimize financial performance and the impact of policy shifts on healthcare access. Whether you’re an insurer, policymaker or healthcare leader, this episode unpacks the latest insights shaping the ACA marketplace.

Listen now to stay informed on the future of ACA and risk adjustment!

Listen Here

Critical Regulatory Updates – Medicare Advantage Impacts

Written by LBodnarchuk on . Posted in Insights.

Setting the Stage for the 2026 Medicare Advantage Rate Announcement

On April 4th and April 7th, 2025, the Centers for Medicare & Medicaid Services (CMS) released 2026 Medicare Advantage Final Rule and 2026 Final Rate Announcement, respectively. These releases outline critical policy updates and payment adjustments that will shape the present and future of Medicare Advantage plans. The impact of these changes and signals present both a challenge and an opportunity for plans to reassess their strategies and adapt to the new normal.

More than Just the Numbers

CMS finalized a 5.06% increase in Medicare Advantage payments for 2026, amounting to $25 billion in additional plan revenue. Big number. Big headline. But the real story is how CMS continues to evolve its role—not just as a payer but as a regulator, standard-setter and advocate for Medicare enrollees. It’s not just how much CMS is investing in the Medicare program, it’s also about the standards for how the they expect plans to operate.

Star Ratings and Measure Impacts: Few Changes but Signals for What’s to Come

From a Stars perspective, these regulatory updates weren’t the tidal wave that some predicted. There was a notable measure rebrand, formerly the Health Equity Index (HEI). The much-maligned measure has been renamed to Excellent Health Outcomes 4 All (EHO4A). This change is not merely cosmetic but signals CMS’s ongoing commitment to reducing cost to the Medicare Advantage program (the true intention of the Health Equity Index anyway). In addition, the possibility of integrating geography as a social risk factor adds an extra layer of complexity for plans to consider. Plans may soon be required to account for geographic location when measuring and addressing health disparities and outcomes – a major nod to challenges in rural health. This could have a profound impact on how programs are designed and how quality measures are calculated, especially in communities facing systemic health challenges.

Finally, CMS has established official deadlines for plans to review and dispute data:

  • May 30, 2025 – CTM data review deadline
  • June 30, 2025 – Appeals data review deadline
  • May 18, 2026 – Part D Patient Safety data review deadline (SY2027)
  • March 31, 2026 – Deadline for all contracts to request a review of 2025 CTM data (SY2027)

With these fixed deadlines for data review, last-minute efforts to improve measure performance may be a challenge due to time constraints. Plans need to be much more proactive and diligent when reviewing their own data and searching for improvement opportunities.

A New Normal: The Need for Innovation in the Evolving CMS Landscape

The changes outlined in the 2026 Medicare Advantage announcements are more than just policy adjustments—they are part of a broader shift in the healthcare landscape. With figures like Dr. Oz and RFK Jr. now influencing the conversation, it’s clear that CMS is moving in a direction that prioritizes innovation, positive health outcomes, efficiency and adaptability.

CMS also showed strong interest in AI and operational efficiency, suggesting this administration is open to exploring technology’s role in modernizing Stars and other quality programs. The emphasis on the Universal Foundation of core measures—and the potential removal of many operational-style metrics—means plans will also need to focus on clinical outcomes, data capture/interoperability and measurement strategy in areas that matter most.

Plans must take a hard look at how they operate today and prepare to adjust their strategies under this new lens. The healthcare industry is entering a “new normal,” where the plans that succeed will be those that innovate and respond proactively to emerging trends. Those that fail to adapt risk falling behind in a competitive market. The future of Medicare Advantage will belong to innovators who can navigate this shifting terrain, ensuring that they are providing high-quality, outcomes driven care that meets the evolving needs of beneficiaries.

Conclusion: Building for the Future By Assessing Your Present

The Rate Announcement and Final Rule aren’t just technical documents—they’re a glimpse into CMS’s evolving philosophy: tighter guardrails, enhanced beneficiary protections and a firmer hand on program integrity and efficiency. The takeaway should be about building health plan infrastructure that can keep up with the direction that CMS is heading.

So, what should plans be doing now? We’re entering a summer and fall that will be filled with speculation, potential demonstration programs and policy previews that will shape 2027 and beyond. But 2026 is already defined—and it presents a critical opportunity for health plans to re-evaluate their Stars strategy, challenge current assumptions and reimagine how performance, data and member experience come together. At ProspHire, we’re working with clients to assess Stars readiness from every angle and every function—clinical workflows, data infrastructure, provider engagement and more. In this moment of change, everything should be on the table: new partnerships, new technologies and bold innovations that improve performance and drive sustainable results.

If your team is looking to get ahead of these changes and set the foundation for long-term success, let’s talk. At ProspHire, we have the experience and expertise in the Medicare Advantage and Stars space and the frameworks for evaluating plans capabilities and Stars potential. The way we approach our assessments of plans is comprehensive and wholistic, understanding that Stars success is about the entire health plan not just one team. Gaining a better understanding of your present, in order to prepare for the future will enable long-term success. Change is hard, but the work we do today will define your outcomes of tomorrow.

Download our Stars Contract Capability Assessment Framework Now!

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Compassion in Action: Supporting Vulnerable Children Beyond Healthcare

Written by LBodnarchuk on . Posted in Insights.

At ProspHire, social responsibility isn’t just a guiding principle—it’s a fundamental part of who we are. As we work toward our mission to help our clients provide better access to quality healthcare, we recognize that true impact goes beyond our profession. It means actively contributing to the well-being of the communities we serve, particularly those most vulnerable. 

One of the most meaningful ways we demonstrate this commitment daily is through our ongoing efforts to improve government programs that provide healthcare to those in greatest need. But our responsibility doesn’t stop there. We understand that healthcare extends beyond policies and programs—it’s about people. That’s why we proudly support the Children’s Hospital of Pittsburgh Child Advocacy Center and its Patient Family Support Fund, which was established and continues to be sustained through ProspHire’s philanthropic support. 

During National Child Abuse Prevention Month, we reaffirm our dedication to protecting and advocating for children who have experienced abuse or neglect. The Patient Family Support Fund ensures that the Child Advocacy Center has a dedicated budget to meet the immediate needs of these children—whether it’s providing essential resources, medical care, or emotional support. This initiative reflects our core belief that healthcare is not just about treatment but also about compassion, advocacy and meaningful action. 

At ProspHire, social responsibility is not just an obligation, it’s a privilege. It’s the reason we do what we do every day and it’s why we will continue to use our expertise, resources and passion to make a tangible difference in the lives of those who need it most. 

Did You Know? 

Children living in poverty are significantly more likely to experience abuse or neglect—and over 70% of children involved in child welfare systems are enrolled in Medicaid or CHIP. That’s why our work to strengthen these public programs and support advocacy organizations is so critical to protecting children and ensuring they receive the care and compassion they need.