The Hidden Economics of Payer Operations

The Cost of Inaction

Rising margin pressure, regulatory demands, and fragmented operations are forcing health plans to confront a difficult question: when does maintaining the current model become more expensive than changing it? This episode examines the often-overlooked cost of inaction—where financial strain, delayed growth opportunities, and operational complexity quietly compound over time. It explores why incremental fixes and point solutions are no longer enough, and how legacy operating structures can limit scalability, responsiveness, and strategic decision-making. At the same time, a shift is underway. A new operating approach is emerging—one that redefines accountability, integrates technology and operations, and introduces predictability into cost structures. What does this shift actually look like in practice, and how can leaders recognize when they’ve reached the tipping point? Listen to the full episode to uncover the signals, tradeoffs, and opportunities shaping the next era of payer operations. About Our Guest:  Ken Dixon works with health plans to determine their readiness to shift away from legacy operating models towards a modernized operating approach, demonstrating clear operational savings of 30-40% PMPM.

The Hidden Economics of Payer Operations

Administrative costs are climbing across the payer industry, but many plans still rely on high-level expense views that mask the true drivers of operational spend. Beneath the surface, fragmented systems, manual processes, and vendor complexity may be shaping financial outcomes more than leaders realize. This episode takes a closer look at how hidden cost dynamics emerge and why understanding the full operating picture is becoming a strategic priority for executive teams. If your organization is questioning whether incremental efficiency gains are enough to protect margins, this conversation offers an important perspective. Listen to explore the forces redefining payer operations and what they could mean for your plan’s financial future. About Our Guest: Missy Andersen is a healthcare operations and advisory leader with experience across consulting, regional health plans, and technology-enabled service models. She specializes in helping payer organizations evaluate their total cost of ownership, operational performance, and organizational design to support more efficient and sustainable operating models.

Stars in Flux: CMS 2027 Changes

Medicare Advantage organizations are facing a significant policy year as CMS releases updates that signal a recalibration of the Stars program and broader regulatory framework. Recent rule-making and guidance point to changes in measurement priorities, simplification efforts, and evolving expectations around quality performance and operational execution. While some updates appear administrative on the surface, they carry implications for how plans evaluate performance, align internal teams, and prepare for future contract years. The episode explores what these federal signals suggest about CMS’s direction and how plans can interpret them within the context of long-term strategy. What do these changes truly mean for 2027 and beyond—and how should payers respond now? Listen to the full episode to uncover the deeper strategic signals shaping the future of Medicare Advantage. About Our Guest: Shelby Jansen has deep expertise in guiding payer quality strategies to meet CMS expectations, reflecting NCQA updates, optimizing Stars and HEDIS programs, and guiding health plans through digital transformation.

Lessons From 2026 Enrollment

Enrollment for 2026 brought major shifts for health plans, driven by new CMS rules, rising consumer expectations, and the growing pressure to modernize operations. This episode explores how plans are rethinking enrollment integrity, broker oversight, digital shopping, data quality, and how emerging interoperability requirements will reshape eligibility, provider data, and automation in the seasons ahead. Tune in to understand how these changes affect the future of enrollment, and how leading plans are preparing now. About Our Guest: Alex Loera oversees the enrollment and billing operations aspect of the BPaaS ecosystem. He specializes in scaling enrollment and billing operations, improving data integrity, and strengthening compliance in high-growth, regulated environments.

The Problem With Managing Multiple Vendors

Is managing multiple vendors slowing your health plan down? Disconnected systems, rising costs, and scattered data often stand in the way of efficiency and better member experiences.  This episode explores the challenge of managing multiple vendors and how health plans can escape this antiquated operating model to simplify operations, cut costs, and gain real-time visibility across business functions. Listen to discover how to drive lasting operational excellence with a single, accountable partner. About Our Guest:  Sean Cattie has deep expertise as a healthcare technology executive focusing on BPaaS delivery models. Sean leads client delivery teams responsible for technical capabilities, implementation governance, automation and configuration across enterprise operations.