Brian D. Pieninck

Nationwide Employer Healthcare Strategy. Claims are running unexpectedly high!! Employers are over budget. Here's what to do... These high healthcare costs are being driven by High Cost Claimants... the 5% of health plan members with high costs that drive 50% of overall health plan spending. Here are 5 Strategies for Employers to Lower High Claimant Healthcare Costs: 1) Network: Switch carriers to the only 1 out of the 4 major insurance carriers that has decent contracts with major hospital systems. 2) Claims Data: Get your claims data including allowed amount (and preferably Billed Charges, Provider NPI number and Provider Tax ID Number). Put your carrier out for RFP if necessary and include this data requirement in your RFP. 3) Engage High Cost Claimants: Use the claims data to identify and assist existing high cost claimants and predict and prevent the most probable future high cost claimants. Use age greater than 50 as an initial screen for these potential high cost claimants. 4) Address Fraud, Waste and Abuse (FWA): Use your claims data to identify fraudulent claims and prevent future payments to that same provider equal to the amount of the fraud. 5) PBM: Carve-out your PBM to a transparent, pass-through PBM that DOES NOT require you to fill your specialty pharmacy medications through the mail order specialty pharmacy that they own. Links to source videos on AHealthcareZ YouTube Channel. #Healthcare #HealthInsurance #EmployeeBenefits

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“ Lincoln Liberty Capital is proud to announce its platform investment in P&A Group, a leading provider of consumer-directed health benefits solutions. P&A partners with employers, brokers, and administrators to deliver flexible spending, HSA, HRA, COBRA, and other benefit programs that empower employees and simplify administration. This investment reflects our focus on partnering with exceptional management teams to build durable, scalable businesses in the employer services and healthcare ecosystem.” #betterhealth

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For too long, our system has focused on the volume of services provided, rather than the quality of care delivered. This approach has led to higher costs and inconsistent outcomes.     I recently participated in a CEO Panel at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum, where we discussed the future of health care delivery innovations. One of the key takeaways from our conversation was the importance of shifting toward rewarding quality over quantity to improve health outcomes, reduce unnecessary costs, and create a more sustainable health care system.      By incentivizing providers based on quality rather than quantity, we can create a more sustainable and effective health care system. This approach, which we've implemented through strong partnerships in our provider networks, has led to improved health outcomes and reduced costs for our members.     For example, the value-based Sanitas care model at our Florida Blue | Sanitas Medical Centers creates more seamless and coordinated care for our members that prioritizes prevention and early intervention. As a result, we've seen measurable reductions in avoidable hospitalizations and improvements in chronic disease management.      I'm proud of the work we're doing at GuideWell to create a more sustainable and effective health care system. By working together with providers and prioritizing the needs of our members, we can create a better future for health care.     #HealthCare #HealthCareOnLinkedIn #Innovation #Sustainability 

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AETNA INSURANCE | 9 Critical Insurance Policy Updates Across Key U.S. States! 1. CA Network Tiering Optimization Aetna has introduced multi-tiered provider access to better align with reimbursement tiers, giving hospitals and practices improved placement for value-based performance and geographic accessibility. Expand your footprint with higher-tier visibility and referral capture.📍 2. TX Telehealth Reimbursement Parity Policy Finalized Aetna has implemented permanent telehealth parity ensuring equal reimbursement for virtual and in-person services, including specialties like mental health, dermatology, and primary care. No rate reduction for tele-visits = more flexibility and profit.💻 3. FL Dental Plan Realignment + Value-Add Services Aetna's dental insurance now includes comprehensive periodontal coverage, in-office whitening, and extended preventive visit limits aligned with employer group demands. Richer benefits = higher treatment acceptance rates.🦷 4. NY Revised Prior Authorization Mandates Under Value Framework Aetna now exempts high-performing providers from certain low-risk prior authorizations, using real-time provider scoring models. Time is money cut red tape for top performers.⏱️ 5. IL Bundled Payments Introduced for Outpatient Procedures New bundled insurance payment options are now live for select ambulatory and surgical center procedures. Bundle billing = less friction, faster reimbursements.💰 6. PA Hospital Readmission Penalty Waivers for Coordinated Providers Aetna will waive penalties on readmissions when practices participate in coordinated discharge and post-acute care models within its insurance framework. Reduce pressure and increase support for continuity of care.🏥 7. OH Enhanced Denial Management Transparency Portal New digital portal offers real-time denial causality insights, historical rejection data, and ICD/CPT justification tools tied to Aetna’s internal adjudication logic. Know why you’re denied- fix it before submission.📋 8. GA Risk Adjustment Incentive Programs for Primary Care Providers Aetna now offers incentives for accurate risk coding, quality gap closures, and preventive measure completion tying these directly into premium adjustments and star ratings. Turn documentation into dollars and better plan ratings.⭐ 9. NC Behavioral Health Carve-In Across Commercial and Medicaid Plans Aetna now fully integrates behavioral health benefits within both commercial and Medicaid managed care plans, eliminating subcontracted coverage for smoother billing and unified benefits. One plan, one policy, no confusion.🧠 Let’s navigate the new insurance! #AetnaInsurance2025 #HealthcareProviders #MedicalBilling #RCMUpdates #InsurancePolicyChange #PracticeManagers #HospitalFinance #ValueBasedCare #DigitalHealth #RevenueCycleManagement #PayerReform #ClaimsEfficiency #InsuranceCoverage #DentalInsurance #BehavioralHealthCare #PriorAuthReform #BundledPayments #RiskAdjustment #LinkedInHealthcare

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