Latest news with #BlackBookResearch
Associated Press
3 days ago
- Business
- Associated Press
Black Book Research Names 2025's Top Vendors in Risk Adjustment & Coding Optimization for Health Plans and Payers
Advanced Analytics, AI, and Automation Become Essential as Payers Face Increased Scrutiny on Risk Adjustment Accuracy and Financial Performance NEW YORK CITY, NY / ACCESS Newswire / June 1, 2025 / As healthcare payers face intensified regulatory oversight, rising healthcare costs, and the evolving complexities of risk adjustment, Black Book Research today announced its 2025 rankings of the leading vendors in Risk Adjustment & Coding Optimization software. These solutions have become essential for payers seeking accurate, compliant, and financially optimized coding practices across Medicare Advantage, Medicaid managed care, ACA marketplace plans, and commercial insurers. According to Black Book's latest payer survey conducted between Q4 2024 and Q1 2025, with responses from 1,108 senior payer executives, finance officers, and risk adjustment leaders, 92% indicated that advanced analytics and artificial intelligence (AI) tools are now critical for accurate risk scoring, improved coding efficiency, and maintaining regulatory compliance. 'Health plans are urgently investing in technology solutions that provide precise, predictive, and fully compliant risk adjustment and coding practices,' said Doug Brown, President of Black Book Research. 'Optimized coding not only ensures regulatory compliance but significantly impacts financial stability, resource allocation, and member care quality.' Scope and Opportunity in Risk Adjustment & Coding Optimization Software The survey highlights a growing emphasis on several core areas where payer software solutions can dramatically enhance performance: Accurate Risk Scoring: 94% of respondents highlighted accuracy in HCC (Hierarchical Condition Categories) and RAF (Risk Adjustment Factor) scoring as their highest priority. Regulatory Compliance: 89% emphasized the importance of software capable of continuous compliance monitoring, automated audits, and coding validation. Predictive Analytics: 87% of payers prioritize advanced analytics solutions that anticipate risk and allow proactive management of populations. Automated Coding Processes: 70% noted the necessity for automation to reduce manual errors, streamline workflows, and accelerate coding accuracy. Interoperability and Data Integration: 66% reported interoperability as essential, ensuring seamless data flow among providers, payers, and regulatory bodies. Top 10 Vendors in Risk Adjustment & Coding Optimization (Ranked by Client Satisfaction and Performance) Edifecs - Distinguished for its robust interoperability solutions and real-time risk adjustment analytics that streamline payer workflows and ensure regulatory accuracy. Apixio - Recognized for its AI-powered risk adjustment analytics, utilizing natural language processing (NLP) to dramatically improve coding accuracy and risk stratification. SCIO Health Analytics (EXL) - Highly rated for predictive modeling and comprehensive analytics tools that significantly enhance coding accuracy, financial forecasting, and compliance management. Advantasure - Praised for its integrated risk adjustment platform, offering real-time analytics, automated chart reviews, and predictive risk identification. Change Healthcare - Valued for sophisticated coding optimization and analytics capabilities, significantly reducing audit risks and improving revenue accuracy. Innovaccer - Noted for advanced analytics and integrated workflows that seamlessly connect payer data streams, optimizing risk management strategies. Inovalon - Applauded for scalable analytics platforms and comprehensive interoperability, enhancing accuracy in risk scoring and regulatory compliance. Cotiviti - Recognized for its deep analytics and precise data validation, enabling payers to accurately capture risk and streamline coding compliance. Optum - Acknowledged for robust AI-driven risk adjustment and coding tools that integrate seamlessly across payer systems, delivering accuracy and compliance. Talix - Renowned for its innovative NLP-driven risk adjustment solutions that ensure precise coding, reducing compliance risk and maximizing revenue integrity. 'Risk adjustment and coding optimization software has become a strategic imperative for payers aiming to thrive in today's regulatory and competitive healthcare environment,' added Brown. 'Leveraging these technologies positions payers not only to achieve compliance but to realize substantial improvements in financial outcomes, operational efficiency, and member health management.' About Black Book Research Black Book Research provides unbiased, crowd-sourced insights into healthcare technology, services, and outsourcing. Since 2004, Black Book has surveyed over 1 million healthcare technology users and buyers, maintaining strict independence without vendor funding, advisory subscriptions, or performance improvement arrangements. To license the full complete 2025 Risk Adjustment & Coding Optimization report and detailed vendor performance metrics, visit: Media Inquiries: Email: [email protected] Contact Information Press Office [email protected] 8008637590 SOURCE: Black Book Research press release
Yahoo
3 days ago
- Business
- Yahoo
Black Book Research Names 2025's Top Vendors in Risk Adjustment & Coding Optimization for Health Plans and Payers
Advanced Analytics, AI, and Automation Become Essential as Payers Face Increased Scrutiny on Risk Adjustment Accuracy and Financial Performance NEW YORK CITY, NY / / June 1, 2025 / As healthcare payers face intensified regulatory oversight, rising healthcare costs, and the evolving complexities of risk adjustment, Black Book Research today announced its 2025 rankings of the leading vendors in Risk Adjustment & Coding Optimization software. These solutions have become essential for payers seeking accurate, compliant, and financially optimized coding practices across Medicare Advantage, Medicaid managed care, ACA marketplace plans, and commercial insurers. According to Black Book's latest payer survey conducted between Q4 2024 and Q1 2025, with responses from 1,108 senior payer executives, finance officers, and risk adjustment leaders, 92% indicated that advanced analytics and artificial intelligence (AI) tools are now critical for accurate risk scoring, improved coding efficiency, and maintaining regulatory compliance. "Health plans are urgently investing in technology solutions that provide precise, predictive, and fully compliant risk adjustment and coding practices," said Doug Brown, President of Black Book Research. "Optimized coding not only ensures regulatory compliance but significantly impacts financial stability, resource allocation, and member care quality." Scope and Opportunity in Risk Adjustment & Coding Optimization Software The survey highlights a growing emphasis on several core areas where payer software solutions can dramatically enhance performance: Accurate Risk Scoring: 94% of respondents highlighted accuracy in HCC (Hierarchical Condition Categories) and RAF (Risk Adjustment Factor) scoring as their highest priority. Regulatory Compliance: 89% emphasized the importance of software capable of continuous compliance monitoring, automated audits, and coding validation. Predictive Analytics: 87% of payers prioritize advanced analytics solutions that anticipate risk and allow proactive management of populations. Automated Coding Processes: 70% noted the necessity for automation to reduce manual errors, streamline workflows, and accelerate coding accuracy. Interoperability and Data Integration: 66% reported interoperability as essential, ensuring seamless data flow among providers, payers, and regulatory bodies. Top 10 Vendors in Risk Adjustment & Coding Optimization (Ranked by Client Satisfaction and Performance) Edifecs - Distinguished for its robust interoperability solutions and real-time risk adjustment analytics that streamline payer workflows and ensure regulatory accuracy. Apixio - Recognized for its AI-powered risk adjustment analytics, utilizing natural language processing (NLP) to dramatically improve coding accuracy and risk stratification. SCIO Health Analytics (EXL) - Highly rated for predictive modeling and comprehensive analytics tools that significantly enhance coding accuracy, financial forecasting, and compliance management. Advantasure - Praised for its integrated risk adjustment platform, offering real-time analytics, automated chart reviews, and predictive risk identification. Change Healthcare - Valued for sophisticated coding optimization and analytics capabilities, significantly reducing audit risks and improving revenue accuracy. Innovaccer - Noted for advanced analytics and integrated workflows that seamlessly connect payer data streams, optimizing risk management strategies. Inovalon - Applauded for scalable analytics platforms and comprehensive interoperability, enhancing accuracy in risk scoring and regulatory compliance. Cotiviti - Recognized for its deep analytics and precise data validation, enabling payers to accurately capture risk and streamline coding compliance. Optum - Acknowledged for robust AI-driven risk adjustment and coding tools that integrate seamlessly across payer systems, delivering accuracy and compliance. Talix - Renowned for its innovative NLP-driven risk adjustment solutions that ensure precise coding, reducing compliance risk and maximizing revenue integrity. "Risk adjustment and coding optimization software has become a strategic imperative for payers aiming to thrive in today's regulatory and competitive healthcare environment," added Brown. "Leveraging these technologies positions payers not only to achieve compliance but to realize substantial improvements in financial outcomes, operational efficiency, and member health management." About Black Book Research Black Book Research provides unbiased, crowd-sourced insights into healthcare technology, services, and outsourcing. Since 2004, Black Book has surveyed over 1 million healthcare technology users and buyers, maintaining strict independence without vendor funding, advisory subscriptions, or performance improvement arrangements. To license the full complete 2025 Risk Adjustment & Coding Optimization report and detailed vendor performance metrics, visit: Media Inquiries: Email: research@ Contact Information Press Office research@ SOURCE: Black Book Research View the original press release on ACCESS Newswire Error in retrieving data Sign in to access your portfolio Error in retrieving data Error in retrieving data Error in retrieving data Error in retrieving data
Associated Press
3 days ago
- Business
- Associated Press
Black Book Research Names 2025's Top-Rated Utilization Management & Prior Authorization Vendors Across All Payer & Health Plan Segments
AI-Driven and Scalable Solutions Lead the Way as Payers Prioritize Efficiency, Compliance, and Member Satisfaction TAMPA, FL / ACCESS Newswire / June 1, 2025 / Amid escalating regulatory requirements, increasing cost pressures, and rising consumer expectations, Black Book Research today announced the top-rated Utilization Management (UM) and Prior Authorization (PA) technology vendors for 2025. Based on extensive feedback from 1,632 verified payer executives, IT directors, and clinical operations leaders surveyed between Q3 2024 and Q2 2025, the report highlights an industry-wide transition toward AI-powered, interoperable solutions across commercial, Medicare Advantage, Medicaid, and employer-sponsored health plans. 'Health plans across the board are rapidly moving away from manual, labor-intensive prior authorization methods,' said Doug Brown, President of Black Book Research. 'The most successful payers are embracing scalable technologies that integrate clinical decision-making, automate processes, ensure compliance, and dramatically improve both provider and member experiences.' Top 10 Vendors in Utilization Management & Prior Authorization Solutions (Ranked by Client Satisfaction and Performance) These vendors are ranked based on client satisfaction, performance, and their ability to deliver scalable, compliant, and intelligent UM/PA solutions across various payer segments: Cohere Health - Renowned for its AI-driven clinical decision workflows that significantly reduce unnecessary prior authorizations and expedite patient care. MCG Health - Praised for evidence-based clinical decision support that enhances accuracy and consistency across utilization reviews. eviCore healthcare - Noted for extensive benefit management capabilities, especially within specialty care authorization and integration. Agadia - Celebrated for customizable electronic prior authorization tools that streamline approval processes and enhance formulary compliance. Availity - Highly rated for real-time payer-provider automation that minimizes friction and strengthens provider relationships. Infinx - Rapidly growing for its predictive analytics and proactive denial prevention technologies, driving measurable ROI. Inovalon - Distinguished for analytics-driven authorization platforms and deep interoperability with existing payer systems. Cotiviti - Valued for concurrent authorization efficiency and accurate clinical-to-financial data alignment. Onyx - Recognized for its FHIR-based prior authorization interoperability solutions, facilitating seamless data exchange and compliance with CMS mandates. Apixio - Leveraging natural language processing (NLP) to efficiently validate medical necessity and automate chart reviews. Evaluating Vendors on 18 Essential Performance Indicators Black Book's independent research assessed vendors across 18 payer-specific key performance indicators (KPIs), including: Automation and Process Efficiency; Clinical Decision Support; Regulatory Compliance; Integration and Interoperability; Member Experience and Provider Satisfaction; and Return on Investment (ROI). 'It's clear that payers aren't just adopting technology for automation's sake,' Brown added. 'The leading solutions in our survey demonstrated measurable improvements in regulatory readiness, member satisfaction, operational cost savings, and value-based care support.' The comprehensive 2025 Black Book Research report evaluates a total of 20 UM/PA technology vendors serving a broad range of payer segments. The insights are invaluable for payer CIOs, clinical management teams, and procurement professionals seeking scalable, compliant, and intelligent utilization management solutions. About Black Book Research Black Book Research, a division of Black Book Market Research LLC, provides unbiased, crowd-sourced insights into healthcare technology, services, and outsourcing. Since 2004, Black Book has surveyed over 1 million healthcare technology users and buyers, upholding a strict policy of independence with no vendor funding, advisory subscriptions, or pay-to-play arrangements. For the report licensing and detailed vendor performance metrics, visit: Media & Report Licensing Inquiries: Email: [email protected] Contact InformationPress Office 8008637590 SOURCE: Black Book Research press release
Associated Press
3 days ago
- Business
- Associated Press
Black Book Research Reveals the Digital Playbook Behind 2025's Top Medicare Advantage and Commercial Health Plans
With Star Ratings Plummeting, New Report Uncovers the Health IT Strategies Used by Elite Plans-and How All Payers Are Leveraging Them to Drive Quality, Retention, and Regulatory Success NEW YORK CITY, NY / ACCESS Newswire / June 1, 2025 / With Medicare Advantage (MA) Star Ratings hitting their lowest average in over a decade, pressure on health plans to perform under intensifying regulatory scrutiny has reached a critical point. In its latest report, 'The 2025 MA Star Ratings Crisis: How Elite Plans Are Using Technology to Succeed Amid Stricter CMS Standards,' Black Book Research reveals the digital strategies and platforms driving measurable results-not only in the Medicare Advantage space but increasingly across all payer types, including commercial insurers, Medicaid managed care organizations, and ACA marketplaces. Only seven MA plans earned a 5-star rating in 2025, down dramatically from 38 in 2024, as CMS raised quality performance thresholds. The technologies adopted by these top-rated plans are now serving as blueprints for broader enterprise transformation across the payer landscape, helping organizations improve quality metrics, elevate member experience, and ensure operational compliance. Independent Survey and Scope This report draws from a comprehensive, independently conducted survey of nearly one thousandsenior IT and operations leaders representing five hundred Medicare Advantage and commercial health plans during Q1-Q2 2025. Over three hundred software vendors were evaluated using eighteen qualitative key performance indicators (KPIs), including: Operational efficiency; Member satisfaction and engagement; Scalability and interoperability; Regulatory compliance; as well as Impact on CMS-aligned metrics (HEDIS, CAHPS, grievance resolution, audit readiness). All findings are vendor-agnostic, independently verified, and free from paid participation or influence. From Medicare to Market-Wide Transformation Technologies originally designed to support Medicare Star Ratings are now redefining success across the entire health insurance industry: Commercial plans are adopting CAHPS-modeled feedback loops and Stars-inspired frameworks to boost loyalty and retention. Medicaid MCOs are integrating grievance tracking, SDoH engagement, and provider network optimization tools rooted in CMS standards. Employer and ACA plans are leveraging analytics, engagement platforms, and gap-closure tools pioneered by leading MA plans. 'Star Ratings may have been designed for Medicare Advantage, but their influence is now systemic,' said Doug Brown, Founder of Black Book Research. 'The digital platforms powering top MA performance are now essential to delivering quality, experience, and efficiency across every payer segment. As regulatory expectations and consumer demands rise, all health plans, whether commercial, Medicaid, or employer-sponsored, have a strategic opportunity to accelerate digital transformation by partnering with proven vendors that consistently deliver measurable impact across the industry.' 10 Critical Technology Clusters Driving Payer Success High-performing plans consistently adopted and scaled solutions in the following key domains: Care Coordination and Chronic Disease Management - Integrated tools improving transitions and reducing avoidable hospitalizations Member Engagement and Experience Personalization - Omnichannel systems optimizing CAHPS-related satisfaction metrics Preventive Services Utilization and Risk Adjustment - Platforms enhancing Stars and HEDIS outcomes Predictive Analytics and AI-Driven Insights - Real-time data models driving targeted population health actions Enterprise Quality Management and Compliance - Solutions aligning with CMS, NCQA, and URAC standards Provider Network Optimization and Collaboration - Tools improving referral flow, directory accuracy, and contract performance Grievance, Appeals, and Case Resolution - Automated workflows ensuring timely regulatory compliance Retention and Loyalty Management - NPS-based tools and churn predictors strengthening member retention Pharmacy and Interdisciplinary Care Integration - Medication safety and alert systems improving outcomes Interoperability and Consent Management - FHIR-enabled APIs and secure data-sharing infrastructure Top 20 Comprehensive MA and Managed Care Vendors Survey respondents from 5-star MA plans and other high-performing organizations identified the following 20 vendors as having the most significant impact across these functional domains. Vendors are listed by functional area and were selected solely based on survey volume and performance context: Inovalon - Industry-leading analytics and quality measurement tools supporting HEDIS and Star Rating improvements Cotiviti - Predictive analytics and data integration for optimized preventive care and risk adjustment Health Catalyst - Real-time insights through advanced data warehousing and AI-enabled dashboards Arcadia - Robust population health management and seamless data aggregation Innovaccer - Unified member records and interoperable care coordination HealthEdge (GuidingCare) - Integrated care management and quality optimization platform Medecision (Aerial) - Predictive workflows improving readmission rates and engagement EXL (CareRadius) - Automation and analytics for managing high-risk populations VirtualHealth (HELIO) - Unified care management enabling real-time clinical interventions ZeOmega (Jiva) - Full-spectrum care management and interoperability boosting satisfaction and Star scores Tabula Rasa HealthCare - Advanced pharmacy solutions reducing adverse drug events Icario - Personalized engagement rooted in behavioral science to drive preventive care mPulse Mobile - Conversational AI improving communication and CAHPS-related experiences Bamboo Health (Collective Medical) - Real-time clinical event notifications improving transitions HealthMine - Multi-channel outreach and analytics elevating preventive utilization ReferWell - Referral management optimizing provider coordination WellSky - SDoH and population health tools reducing preventable admissions HealthCrowd - Behavioral engagement and screening adherence improvement Convey Health Solutions - Automated grievance and appeals management for enhanced MA operations Zipari - Consumer experience platform supporting engagement, retention, and Stars performance Raising the Bar for All Payer Segments Findings from the 2025 survey confirm a growing trend: the same technologies that drive MA excellence are now enhancing delivery, satisfaction, and outcomes across all health plan types. Notable applications include: Commercial Insurance: CAHPS-modeled feedback loops and digital experience benchmarking Medicaid: Stars-style performance tracking, SDoH engagement, and compliance analytics Employer Plans: NPS tracking, retention modeling, and personalized engagement All Payers: Unified data platforms and real-time insights through expanded interoperability investments Access the Full Report The full report, 'The 2025 MA Star Ratings Crisis: How Elite Plans Are Using Technology to Succeed,' including detailed KPI frameworks, vendor-functionality mapping, and survey methodology, is now available at: Media inquiries, payer-specific briefings, or customized presentations for Medicare, Medicaid, or Commercial audiences: [email protected] Contact InformationPress Office 8008637590 SOURCE: Black Book Research press release
Yahoo
3 days ago
- Business
- Yahoo
Black Book Research Names 2025's Top-Rated Utilization Management & Prior Authorization Vendors Across All Payer & Health Plan Segments
AI-Driven and Scalable Solutions Lead the Way as Payers Prioritize Efficiency, Compliance, and Member Satisfaction TAMPA, FL / / June 1, 2025 / Amid escalating regulatory requirements, increasing cost pressures, and rising consumer expectations, Black Book Research today announced the top-rated Utilization Management (UM) and Prior Authorization (PA) technology vendors for 2025. Based on extensive feedback from 1,632 verified payer executives, IT directors, and clinical operations leaders surveyed between Q3 2024 and Q2 2025, the report highlights an industry-wide transition toward AI-powered, interoperable solutions across commercial, Medicare Advantage, Medicaid, and employer-sponsored health plans. "Health plans across the board are rapidly moving away from manual, labor-intensive prior authorization methods," said Doug Brown, President of Black Book Research. "The most successful payers are embracing scalable technologies that integrate clinical decision-making, automate processes, ensure compliance, and dramatically improve both provider and member experiences." Top 10 Vendors in Utilization Management & Prior Authorization Solutions (Ranked by Client Satisfaction and Performance) These vendors are ranked based on client satisfaction, performance, and their ability to deliver scalable, compliant, and intelligent UM/PA solutions across various payer segments: Cohere Health - Renowned for its AI-driven clinical decision workflows that significantly reduce unnecessary prior authorizations and expedite patient care. MCG Health - Praised for evidence-based clinical decision support that enhances accuracy and consistency across utilization reviews. eviCore healthcare - Noted for extensive benefit management capabilities, especially within specialty care authorization and integration. Agadia - Celebrated for customizable electronic prior authorization tools that streamline approval processes and enhance formulary compliance. Availity - Highly rated for real-time payer-provider automation that minimizes friction and strengthens provider relationships. Infinx - Rapidly growing for its predictive analytics and proactive denial prevention technologies, driving measurable ROI. Inovalon - Distinguished for analytics-driven authorization platforms and deep interoperability with existing payer systems. Cotiviti - Valued for concurrent authorization efficiency and accurate clinical-to-financial data alignment. Onyx - Recognized for its FHIR-based prior authorization interoperability solutions, facilitating seamless data exchange and compliance with CMS mandates. Apixio - Leveraging natural language processing (NLP) to efficiently validate medical necessity and automate chart reviews. Evaluating Vendors on 18 Essential Performance Indicators Black Book's independent research assessed vendors across 18 payer-specific key performance indicators (KPIs), including: Automation and Process Efficiency; Clinical Decision Support; Regulatory Compliance; Integration and Interoperability; Member Experience and Provider Satisfaction; and Return on Investment (ROI). "It's clear that payers aren't just adopting technology for automation's sake," Brown added. "The leading solutions in our survey demonstrated measurable improvements in regulatory readiness, member satisfaction, operational cost savings, and value-based care support." The comprehensive 2025 Black Book Research report evaluates a total of 20 UM/PA technology vendors serving a broad range of payer segments. The insights are invaluable for payer CIOs, clinical management teams, and procurement professionals seeking scalable, compliant, and intelligent utilization management solutions. About Black Book Research Black Book Research, a division of Black Book Market Research LLC, provides unbiased, crowd-sourced insights into healthcare technology, services, and outsourcing. Since 2004, Black Book has surveyed over 1 million healthcare technology users and buyers, upholding a strict policy of independence with no vendor funding, advisory subscriptions, or pay-to-play arrangements. For the report licensing and detailed vendor performance metrics, visit: Media & Report Licensing Inquiries:Email: research@ Contact Information Press Office research@ SOURCE: Black Book Research View the original press release on ACCESS Newswire Error in retrieving data Sign in to access your portfolio Error in retrieving data Error in retrieving data Error in retrieving data Error in retrieving data
