The healthcare industry in the United States is heavily regulated, and this includes the use of technology in healthcare. It pays to be subject matter experts in the healthcare regulatory environment because regulations have a significant impact on the development and implementation of healthcare technology, from storing data securely to getting paid commensurately. That’s why our founders and team at GenHealth have spent years deep in the industry working with health insurance plans, provider organizations, and life-sciences to help build and navigate in the industry.

Our Experience

The GenHealth.ai team understands in detail the nuances of Medicare regulations and guidelines. Our team comes from years of experience working deeply with dozens of health plans for compliance and reporting.

We have worked with various payment methodologies across both payers and providers including Medicare Advantage, Medicare Fee for Services, Accountable Care Organizations (including commercial, MSSP, and others), MIPS, MACRA, and more. Our experience stems from years of working in the industry closely with both health insurance plans and providers organizations.

Payers and Providers

We are experienced with performance measures for both payers and providers.

Performance measures for the health plans GenHealth works with typically include metrics related to quality of care, patient satisfaction, and cost management. Examples include HEDIS and STARS quality measures. Health plans may also be evaluated based on their ability to manage chronic conditions, prevent hospital readmissions, and ensure beneficiaries receive recommended screenings and vaccinations via other contractual requirements with states under various Medicaid programs.

GenHealth’s team is also experienced with performance measures for providers including metrics related to patient outcomes, quality of care, and cost management. Examples of these measures include the MIPS, MACRA, and various ACO programs, which evaluates providers based on quality, improvement activities, promoting interoperability, episodes of care, bundled payments, and cost. Additionally, under other contractual requirements providers may be evaluated based on their ability to manage chronic conditions, prevent hospital readmissions, and provide appropriate care to patients.

Industry Relationships

GenHealth’s CEO Ricky Sahu has worked closely with regulators and health plans for nearly a decade managing data for 50M patients across dozens of health insurers. Specifically, Aneesh Chopra (first CTO of US and current President of CareJourney) and Don Rucker (former National Coordinator of the ONC and Chief Strategy Officer at 1upHealth) have worked closely with Ricky in the past and continue to support him as Advisors to GenHealth. GenHealth collaborates with the industry standards groups and leaders of organizations like NCQA and their CTO Ed Yurcisin (who Ricky has also worked with). With all of this collaboration, GenHealth often understands the regulatory landscape before it is officially announced and shared broadly. Of course after the announcement of new regs, the GenHealth team works with regulators to both improve and implement the rules. Ricky and his team both at GenHealth and 1upHealth (form which GenHealth spun out) have in the past provided a platform (https://www.virtualhealthconference.com/ and https://www.youtube.com/XuJ47lE9GiU) for regulators to share their new rules with an audience of thousands including most health plans.

Outlook

While these regulations can sometimes be seen as a barrier to innovation, they are also an important safeguard for patients. By ensuring that healthcare technology is safe, effective, and reliable, regulations can help to improve the overall quality of care that patients receive. As healthcare technology continues to evolve, it will be important for companies to balance the need for innovation with the need for compliance with regulations and guidelines.