Author: Gianna DiLauro

Medicaid Readiness Starts Now: Early Lessons for Health Plans

Written by Gianna DiLauro on . Posted in Insights, Medicaid.

States and health plans are navigating overlapping Medicaid changes on compressed timelines. The January 1, 2027, changes under OB3, including six-month renewals for expansion adults, community engagement requirements and reduced retroactive coverage, rightly command attention. But readiness is already being tested by changes taking effect this fall.  

October 1 brought narrower federal Medicaid and CHIP eligibility for certain noncitizens. Separately, a CMS final rule taking effect October 13 restricts federal Medicaid and CHIP funding for certain gender-affirming medical care for minors.  These changes require plans to coordinate member notices, benefit configuration and provider communication. As states determine their responses, early engagement with state agencies can help plans anticipate operational needs and support affected members. The lessons emerging now should inform preparations for January. 

Medical Frailty: Early Lessons From Nebraska 

Medical frailty remains a key area of uncertainty. CMS’s June interim final rule ties frailty to whether a condition significantly impairs a person’s ability to work or take part in qualifying activities and it stops short of providing a diagnosis list, leaving states to define much of it. Nebraska, which began applying work requirements to new applicants May 1, offers an early look at what that means. The state built a nearly 300-page index of diagnosis and procedure codes before the federal rule landed. CMS has since directed Nebraska to revise its medical frailty verification process to align with federal requirements. Early state data show that 39% of new applicants and 57% of renewing members qualified for an exclusion and medical frailty was the largest category among applicants. The lesson for plans is that frailty determinations will carry a great deal of weight and plans hold much of the claims and encounter data states will rely on to make them. 

What Health Plans Can Do Now 

That is why we encourage plan leaders to monitor how each state is defining and verifying medical frailty and to engage their state agency early and collaboratively. Working with state partners, where possible, can help plans clarify documentation and verification processes, support consistent application of medical frailty criteria and protect access to care for eligible members. Plans can begin assessing members now, identify who may be affected and prepare to help members maintain coverage through outreach and education, assistance gathering documentation or referrals to qualifying programs. Unclear notices and missed deadlines can put members’ coverage at risk, making clear, repeated, multi-channel communication essential. 

Key Dates at a Glance 
  • October 1, 2026: Federal Medicaid and CHIP eligibility narrows for certain noncitizens and federal funding for emergency Medicaid for noncitizens is limited. 
  • October 13, 2026: Federal Medicaid and CHIP funding ends for gender affirming medical care for minors (Medicaid under 18, CHIP under 19), with a taper of up to six months for current hormone therapy. 
  • January 1, 2027: Six-month renewals begin for most expansion adults, community engagement requirements begin and retroactive coverage is reduced (one month for expansion adults, two months for other groups and optional CHIP retroactive coverage drops to two months). 
  • October 1, 2028: Cost sharing begins for expansion adults above 100% FPL. 
How ProspHire Can Help

ProspHire helps health plans translate changing Medicaid requirements into practical implementation plans. Our team can support readiness assessments, coordination with state agencies, operational planning and member communication strategies. As OB3 implementation unfolds alongside other Medicaid changes, we help plans identify gaps, prioritize next steps and prepare to support affected members. 

Connect with our team to discuss your organization’s Medicaid readiness priorities. 

October’s Medicaid Eligibility Changes: Lessons for MCO Readiness in 2027

Written by Gianna DiLauro on . Posted in Insights, Medicaid.

New federal eligibility restrictions take effect October 1, 2026. For Medicaid managed care organizations, the effects can extend beyond enrollment.

Beginning October 1, 2026, the federal reconciliation law enacted in 2025 limits eligibility for federally funded Medicaid to certain immigration statuses. Some members covered today may lose coverage, depending on their circumstances and state coverage options.

The number of affected members will vary by plan. For MCOs, the immediate priority is supporting those members through the transition. The experience can also reveal gaps in communication, enrollment coordination and care transitions that warrant attention ahead of Medicaid work requirements beginning in 2027.
Operations feel it first

Eligibility changes flow straight into plan operations. Enrollment files change. Member records need to be reconciled. Call volumes may rise. Care management caseloads may shift, sometimes in the middle of treatment.

Plans should know which members are affected, how terminations will come through from the state and how teams will respond when members call with questions.

Members losing coverage still need support

Losing coverage does not end a member’s health needs. A member managing diabetes or a behavioral health condition still needs care after October 1, 2026.

MCOs have a role in that transition: clear communication, warm handoffs to community resources and continuity plans for members in active treatment.

The impact extends into the community

When coverage ends, the need moves somewhere else. Hospitals may see more uncompensated care. Community-based organizations may see more demand without more funding.

MCOs that understand these downstream effects can strengthen their provider and community partnerships instead of straining them.

Treat October 1 as a preview

Medicaid work requirements are scheduled to begin January 1, 2027, for certain adults, with exemptions and the option for states to implement earlier. Although the eligibility rules and affected populations differ, some operational lessons will carry forward.

What MCOs learn over the next three months (what drives calls, where communication falls short, where handoffs break down, how providers are affected) can inform preparation for those requirements.

Even plans with few affected members can use this period to review how well their processes support coverage transitions.

How ProspHire Can Help

ProspHire helps MCOs turn regulatory change into operational readiness. That can include assessing member and operational impacts, building transition support for members losing coverage, strengthening communication with providers and community partners and applying lessons from October 1 to work requirements readiness.

Because the next change is already on the calendar.

ProspHire Ranks #35 in Modern Healthcare’s 2026 Best Places to Work

Written by Gianna DiLauro on . Posted in News.

Pittsburgh, PA – September 18, 2026

ProspHire, a leading healthcare consulting firm focused on strategy and execution, has been ranked #35 in the Supplier Group in Modern Healthcare’s 2026 Best Places to Work.

This recognition reflects ProspHire’s continued commitment to building and inclusive, collaborative and high-performing workplace where employees have opportunities to grow, lead and make a meaningful impact. The firm’s focus on its people, professional growth and meaningful client work continues to shape the employee experience as ProspHire grows.

“Being recognized as one of Modern Healthcare’s Best Places to Work is especially meaningful because it reflects the experience of our people,” said Lauren Miladinovich, CEO, Managing Principal and Co-Founder. “As ProspHire continues to grow and evolve, we’re intentional about creating opportunities for our people to grow with us, take ownership and make an impact. Our culture has always been one of our greatest strengths and protecting that while continuing to raise the bar is incredibly important to me.”

Chris Miladinovich, Co-Founder and Chief Strategy Officer, added, “The work we do is challenging, and that’s exactly why culture matters. We want people to feel connected to the team, trusted to lead and proud of the impact they’re making for our clients. Being a great place to work isn’t something we accomplish once. It’s something we have to keep learning as we grow.”

ProspHire’s team-driven approach, combined with its focus on execution, empowers employees to contribute to complex and transformative initiatives across healthcare, excellence, including Medicaid, Medicare Advantage, ACA and Dental Practice Management.

For more information about ProspHire, visit prosphire.com.

Soaring to New Health Blog, Season 4 Episode 5

Written by Gianna DiLauro on . Posted in Blog, News.

The State of Managed Care in 2026: Execution Is the Differentiator

Managed care organizations are navigating an increasingly complex environment.

Rising healthcare costs, changing Medicaid enrollment, regulatory shifts, access challenges and evolving member expectations are converging at the same time. For health plans, the challenge isn’t simply understanding what’s changing. It’s having the operational capacity to respond.

That was a central theme in a recent Soaring to New Health conversation with Victor Fields, President and CEO of Highmark Wholecare, and Joe Glinka, Director, Pennsylvania HealthChoices.

Their message for managed care leaders was clear: strategy matters, but execution is becoming the differentiator.

Complexity Is Becoming an Operational Challenge

Policy, funding and market changes don’t happen in isolation.

A change in eligibility can affect enrollment, member communications and care management. Rising pharmacy and medical costs create additional financial pressure. New regulatory requirements introduce technology, data, staffing and implementation needs.

At the same time, health plans are being held to increasingly high expectations around quality, access and member experience.

That means organizations need more than a strong strategy. They need the people, processes, technology and data to turn that strategy into action.

Access Starts with Understanding the Member

Access remains one of the clearest examples of the gap between strategy and operational reality.

Highmark Wholecare serves 27 Pennsylvania counties, 16 of which are considered rural. For members in those communities, accessing care can involve provider availability, transportation, distance and other challenges that extend well beyond the health plan itself.

Those barriers become even more complex for Medicaid and Dual Eligible Special Needs Plan populations.

Fields described the importance of approaching member experience through the “Platinum Rule”: treat others the way they want to be treated.

For health plans, that means understanding what members actually need and designing operations around those realities.

Data can help identify risk and opportunity, but Fields emphasized another critical distinction: outreach isn’t the same as engagement.

High-performing organizations don’t stop at measuring whether they contacted a member. They determine whether the member actually engaged and whether the communication loop was closed.

Operational Readiness Has to Keep Pace with Change

Growth and change both require capacity.

Fields have framed that capacity around four areas: people, process, technology and data.

The strongest organizations aren’t building solely for today’s needs. They’re anticipating what may be required next.

That becomes particularly important as policy changes move toward implementation. Regulatory requirements can trigger changes across eligibility, workflows, technology, data exchange, staffing and member communications and those changes can’t always be operationalized overnight.

Organizations don’t necessarily need every regulatory detail finalized before they begin preparing.

They can assess potential impacts, identify dependencies, evaluate capacity and determine where implementation risk may exist.

That readiness creates flexibility when requirements become clearer.

Technology Should Create More Capacity for Human Connection

Technology and AI will play an increasingly important role in managed care.

Predictive analytics can help organizations identify emerging risk. Automation can reduce administrative burden. Digital tools can improve member communications. Technologies such as ambient listening may give care managers more time to focus on care instead of documentation.

But technology alone isn’t the end goal.

As Fields noted, managed care must remain a human business.

The opportunity is to use technology to create capacity for better engagement, not simply replace human interaction.

That balance may become increasingly important as health plans look for ways to operate more efficiently while improving member experience.

Execution Is the Differentiator

Managed care organizations can’t control every policy change, funding decision or market shift.

They can control how prepared they are to respond.

That means investing in capacity before it becomes a constraint, understanding members before designing solutions, connecting policy decisions to operational requirements and building organizations that can adapt when conditions change.

The organizations that thrive won’t necessarily be those that predict every change.

They’ll be the ones prepared to execute when change arrives.

Listen to the full Soaring to New Health conversation with Victor Fields and Joe Glinka for more perspectives on the state of managed care and what leaders should be preparing for next: Soaring to New Health

Frequently Asked Questions About CMS Reporting Requirements

Written by Gianna DiLauro on . Posted in Insights.

1. What Are the New CMS Reporting Requirements?

CMS is expanding oversight of utilization management (UM) programs to ensure health plans deliver timely, appropriate, and high-quality care. Plans must now submit detailed reports on how they implement UM policies, track denials, appeals and decisions, and monitor clinical and operational outcomes.

2. Why Is This Important for Health Plans?

These requirements are about more than compliance—they impact member experience, clinical quality, and financial performance. Staying ahead of these reporting expectations reduces the risk of penalties, supports transparent operations, and strengthens trust with regulators and members alike.

3. How Will These Reporting Changes Affect Daily Operations?

Health plans may see increased workload in areas such as:

  • Collecting and analyzing UM data
  • Tracking and documenting denials and appeals
  • Monitoring adherence to clinical guidelines
  • Demonstrating compliance across all lines of business

4. What Challenges Might Health Plans Face in Adapting to These Requirements?

Many organizations struggle with:

  • Fragmented data sources
  • Limited integration between UM systems and reporting tools
  • Ensuring consistent documentation across teams and regions
  • Translating regulatory guidance into actionable operational workflows

5. How Can ProspHire Help Health Plans Respond Effectively?

ProspHire partners with health plans to:

  • Assess readiness for CMS reporting and UM oversight
  • Streamline data collection and reporting processes
  • Optimize operational workflows to ensure compliance
  • Provide actionable insights to improve UM program performance and member outcomes

6. What’s the Bottom Line for CMS?

CMS’s new reporting requirements are a signal that transparent, efficient, and clinically sound utilization management is critical. With the right strategy, processes, and support, health plans can meet regulatory expectations, reduce risk and improve care delivery—turning compliance into a competitive advantage.

Frequently Asked Questions On Improving Operational Efficiency in Healthcare

Written by Gianna DiLauro on . Posted in Insights.

1. Why Is Operational Efficiency So Important in Healthcare?

Operational efficiency isn’t just about cutting costs—it’s about optimizing resources, enhancing member experience, and empowering teams to focus on what matters most: quality care. Efficient processes reduce waste, improve outcomes, and allow health plans to respond quickly to regulatory and market changes.

2. What Are the Common Operational Challenges Healthcare Organizations Face?

Many health plans and providers struggle with:

  • Inefficient workflows that slow down decision-making
  • Redundant administrative tasks that drain resources
  • Fragmented data systems that limit visibility
  • Misaligned priorities between clinical, operational, and administrative teams

3. How Can Organizations Identify Areas for Improvement?

Start by taking a data-driven approach:

  • Map workflows to identify bottlenecks
  • Analyze time and resource allocation across teams
  • Review technology utilization to ensure systems are fully leveraged
  • Benchmark against industry best practices to set clear improvement goals

4. What Practical Steps Can Improve Operational Efficiency?

Healthcare organizations can:

  • Standardize processes to reduce variability
  • Automate repetitive tasks where possible
  • Implement integrated systems to unify data and reporting
  • Repurpose resources toward high-value activities that directly impact care delivery

5. How Does Operational Efficiency Impact Patients and Members?

Streamlined operations mean:

  • Faster response times
  • Fewer errors and delays
  • Improved coordination across care teams
  • Higher satisfaction and better health outcomes

6. How Can ProspHire Support Healthcare Organizations in This Area?

ProspHire partners with health plans and providers to:

  • Conduct operational assessments and identify inefficiencies
  • Implement cost-saving process improvements without compromising quality
  • Design workflows that boost productivity and staff engagement
  • Deliver measurable results that enhance care delivery and member satisfaction

7. What’s the Key Takeaway?

Operational efficiency is a strategic advantage. By optimizing processes, leveraging technology, and aligning resources with organizational goals, healthcare organizations can improve outcomes, reduce costs, and deliver a better experience for members and staff alike.

Frequently Asked Questions on Compliance in Healthcare – Navigating Regulatory Changes

Written by Gianna DiLauro on . Posted in Insights.

1. Why is Compliance in Healthcare So Important Right Now?

Healthcare regulations are constantly evolving and staying compliant is critical to protecting patient safety, safeguarding revenue and avoiding costly penalties. Proactive compliance ensures that your organization is prepared for audits, maintains trust with patients and operates efficiently in a complex regulatory landscape.

2. What Are the Biggest Regulatory Challenges Health Plans Face Today?

Health plans must navigate a range of federal and state regulations, including CMS guidelines, ACA marketplace requirements, Medicaid policies and evolving Medicare Advantage rules. These changes can affect product design, reporting requirements, reimbursement models and risk management.

3. How Do Regulatory Changes Impact Operations and Revenue?

Even minor adjustments in regulations can ripple across your organization. For example:

  • Reporting delays or errors can trigger penalties.
  • Changes in risk adjustment models affect financial performance.
  • Updated care requirements can impact operational workflows and resource allocation.

4. How Can Organizations Stay Ahead of Compliance Changes?

A proactive approach includes:

  • Continuous monitoring of regulatory updates
  • Cross-functional collaboration between compliance, operations and clinical teams
  • Implementing process improvements to quickly adapt to new requirements
  • Leveraging expert guidance and consulting support for strategy and execution

5. What Role Does Technology Play in Compliance?

Advanced systems can streamline data reporting, track regulatory deadlines and flag potential issues before they escalate. Integrating compliance technology helps health plans reduce administrative burden, improve accuracy and respond faster to regulatory changes.

6. How Can ProspHire Support Healthcare Organizations with Compliance?

ProspHire provides strategic guidance and hands-on support to help organizations:

  • Assess current compliance risks and gaps
  • Implement process and operational improvements
  • Stay aligned with the latest regulatory updates
  • Enhance data reporting, risk management and operational efficiency

7. What is the Bottom Line?

Effective compliance isn’t just about avoiding penalties—it’s about ensuring operational excellence, safeguarding revenue and maintaining trust with patients and regulators. With the right strategies and support, healthcare organizations can navigate regulatory changes confidently and efficiently.

Project Management in Healthcare – FAQs, Key Insights and Methodologies

Written by Gianna DiLauro on . Posted in Insights.

1. Why Is Project Management Critical in Healthcare?

Healthcare is complex, fast-paced, and highly regulated. Effective project management ensures that initiatives—from technology implementations to process improvements—are delivered on time, on budget, and with measurable impact. It aligns teams, mitigates risk, and supports better patient and member outcomes.

2. What Challenges Do Healthcare Organizations Face Without Strong Project Management?

Without structured project management, organizations often encounter:

  • Missed deadlines and delayed implementations
  • Budget overruns and inefficient resource use
  • Poor communication across teams
  • Reduced quality and inconsistent outcomes
  • Difficulty tracking and demonstrating ROI

3. What Are the Key Project Management Methodologies Used in Healthcare?

The blog highlights five proven approaches:

  • Waterfall – Sequential planning for projects with clearly defined steps
  • Agile – Iterative, flexible approach to adapt quickly to changes
  • Scrum – Agile-based framework for collaborative, team-driven projects
  • Lean – Focus on eliminating waste and improving efficiency
  • Six Sigma – Data-driven methodology to reduce errors and improve quality

4. How Do These Methodologies Improve Healthcare Project Outcomes?

Each methodology helps organizations:

  • Standardize and streamline processes
  • Adapt to regulatory or operational changes
  • Optimize team collaboration and accountability
  • Deliver initiatives with measurable impact on cost, quality, and patient/member experience

5. How Can Healthcare Organizations Choose the Right Methodology?

Selecting the right approach depends on:

  • Project scope and complexity
  • Regulatory or compliance requirements
  • Team structure and stakeholder involvement
  • Desired speed and flexibility

6. How Does ProspHire Help Healthcare Organizations With Project Management?

ProspHire brings hands-on expertise to guide healthcare organizations in:

  • Assessing project readiness and risk
  • Choosing the right methodology for each initiative
  • Aligning cross-functional teams for seamless execution
  • Driving measurable results while keeping projects on schedule and budget

7. What’s the Key Takeaway?

Strong project management is more than a tool—it’s a strategic capability. By applying the right methodologies and leveraging expert guidance, healthcare organizations can deliver complex initiatives efficiently, mitigate risk, and achieve better outcomes for patients, members, and the organization.

Frequently Asked Questions About System Integration in Healthcare

Written by Gianna DiLauro on . Posted in Insights.

1. What is System Integration in Healthcare?

System integration in healthcare refers to the process of connecting various software applications, databases and medical devices within a healthcare organization to ensure seamless data flow, reduce duplication and improve patient care. It enables staff to access the right information at the right time.

2. Why is System Integration Important for Healthcare Organizations?

Integrated systems streamline workflows, reduce administrative burden, improve data accuracy, enhance patient safety and support regulatory compliance. Organizations with integrated systems can make faster, data-driven decisions that improve care outcomes and operational efficiency.

3. What Are the Key Benefits of Healthcare System Integration?

  • Improved Patient Care: Clinicians have real-time access to comprehensive patient data. 
  • Operational Efficiency: Automated processes reduce manual entry and administrative tasks. 
  • Regulatory Compliance: Easier reporting and adherence to standards like HIPAA. 
  • Data-Driven Insights: Analytics across systems help identify trends, gaps and opportunities. 
  • Cost Savings: Reduces inefficiencies and redundant systems. 

4. What Challenges Do Healthcare Organizations Face During System Integration?

Common challenges include legacy systems that don’t communicate well, data privacy concerns, high costs of implementation and ensuring staff adoption. Proper planning and expert guidance are crucial for success.

5. How Does System Integration Impact Patient Experience?

Patients benefit from smoother care coordination, fewer errors, faster service and better access to their medical records. Integrated systems also help reduce wait times and improve communication between providers.

6. What Types of Healthcare Systems Are Typically Integrated?

Healthcare systems typically integrated include:

  • Electronic Health Records (EHR) 
  • Practice Management Systems (PMS) 
  • Revenue Cycle Management (RCM) platforms 
  • Laboratory and diagnostic systems 
  • Telehealth platforms 
  • Billing and insurance systems 

7. How Can Healthcare Organizations Ensure Successful System Integration?

Success depends on thorough needs assessment, selecting the right technology, involving stakeholders early, robust data governance and phased implementation with ongoing training and support.

8. Can Small Healthcare Practices Benefit from System Integration?

Absolutely. Even smaller practices can see significant improvements in workflow efficiency, patient satisfaction and reporting accuracy by integrating key systems, often with scalable cloud-based solutions.

9. How Does ProspHire Help with Healthcare System Integration?

ProspHire partners with healthcare organizations to assess existing systems, design integration strategies, select the right platforms and support implementation. Our team ensures that technology investments align with business goals and patient care objectives