Claims Reimbursement

OIG: Improve Medicare rate-setting for clinical diagnostic lab tests

April 12, 2024 - CMS’ procedures for setting Medicare rates for clinical diagnostic lab tests could improve for future public health emergencies, according to a new report from the Office of the Inspector General (OIG). OIG said in the report that, during the COVID-19 public health emergency, current Medicare rate-setting procedures “did not allow the...

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CMS proposes FY 2025 Medicare payment rates for hospice, IPFs

by Jacqueline LaPointe

CMS proposes a 2.6% hospice payment update for the fiscal year (FY) 2025, which would add about $705 million to payments versus this year. The newly proposed rule (CM-1810-P) states the update comes...

Private payers initially deny nearly 15% of medical claims

by Jacqueline LaPointe

It may take some time to get paid for medical services, suggests a new survey of hospitals, health systems and post-acute care providers. Nearly 15 percent of medical claims submitted to private...

Lower reimbursement rates, denials behind razor-thin margins

by Jacqueline LaPointe

Hospitals and health systems are operating on razor-thin margins as reimbursement rates and denials create financial woes, a new survey indicates. The survey conducted by the Healthcare Financial...

Understanding the Value-Based Reimbursement Model Landscape

by Editorial Staff

The Centers for Medicare and Medicaid Services (CMS) aims to have all traditional Medicare beneficiaries under a value-based care model by 2030. Although the pace may be slow, the healthcare industry is shifting away from fee-for-service...

Medicare Advantage Denials Jump 56%, Commercial Denials 20%

by Jacqueline LaPointe

Hospitals and health systems have seen a significant spike in claim denials as Medicare Advantage and commercial payers deny more of their reimbursement. A new analysis of data from over 1,300...

Surprise Billing Proposals Aim to Streamline IDR Process

by Victoria Bailey

The Biden-Harris Administration has released a proposed rule to improve the independent dispute resolution (IDR) process for surprise billing by addressing payer-provider communication and adjusting...

Patient Access, Registration Errors Lead to Most Claim Denials

by Jacqueline LaPointe

Hospitals and health systems are facing more claim denials as front-end revenue cycle processes lead to errors. A recent survey conducted by the Healthcare Financial Management Association’s...

Claims Reimbursement Speed, Denial Rate Tied to Location

by Jacqueline LaPointe

Does your practice experience claims reimbursement delays? That may be because of where your practice operates, according to a recent analysis of financial transaction data. The new Crowe report,...

Claim Denials Pose Expensive Problem for Providers

by Jacqueline LaPointe

Claim denials are posing a serious and expensive problem for healthcare revenue cycle management (RCM), according to a recent survey of healthcare leaders. A survey conducted by Plutus Health...

AMA 2024 CPT Code Set Addresses Language Barriers, Immunization Codes

by Victoria Bailey

The American Medical Association (AMA) has released the 2024 Current Procedural Terminology (CPT) code set, which addresses language barriers by including Spanish descriptors of medical services. Each...

CMS Reduces No Surprises Act Fee After Court Vacates Price Hike

by Jacqueline LaPointe

CMS has reinstated the $50 fee for initiating a payment dispute under the No Surprises Act following a court ruling striking down a price hike earlier this year. The non-refundable administrative fee...

What Payment Integrity Means for Providers, How to Avoid Claim Issues

by Jacqueline LaPointe

Healthcare providers are constantly running into payment integrity tools payers put in place to ensure proper payment. But payment integrity is also crucial for providers if they want accurate, complete, and timely reimbursement. Of the...

CMS Proposes 1.6% Payment Increase for ESRD Facilities

by Jacqueline LaPointe

CMS has released a proposed rule for the end-stage renal disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to Medicare beneficiaries on or after January 1, 2024. The...

Back to the Basics, Other Payment Integrity Strategies Post-PHE

by Jacqueline LaPointe

After an unprecedented three years, it’s time to return to the basics, according to Jordan Kearney, partner at Hooper, Lundy, and Bookman and founder of the firm’s Medicare Audits and Appeals Practice Group. By that, she means...

CMS Announces Start Date for IRF Claims Review Demo

by Jacqueline LaPointe

Inpatient rehabilitation facilities (IRFs) will have their Medicare claims reviewed either before or after payment as part of a demonstration CMS intends to take nationwide. CMS recently announced on...

Independent Dispute Resolution Case Load 14X More Than Expected

by Jacqueline LaPointe

Nearly a year after the federal government launched the independent dispute resolution (IDR) process under the No Surprises Act, over 330,000 balance billing disputes have been filed, nearly 14 times...

Lawmakers Want to Tie Physician Payment Updates to Inflation

by Jacqueline LaPointe

Several lawmakers are seeking to tie physician payment updates in Medicare to inflation to prevent potential physician shortage issues. Representatives Raul Ruiz, MD (D-CA-25), Larry Bucshon, MD...

Proposed Rule to Boost Medicare Inpatient Rehab Payments by 3%

by Jacqueline LaPointe

A new proposed rule from CMS would increase payments to inpatient rehabilitation facilities (IRFs) by $335 million next fiscal year. The draft regulation would also update quality reporting and new...

AHA, AHIP Urge Supreme Court to Uphold False Claims Act Ruling

by Victoria Bailey

The American Hospital Association (AHA) and AHIP have filed an amicus brief challenging the federal government’s interpretation of the False Claims Act, stating that it would adversely impact...

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