Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Claims Management

3 Strategies to Minimize the Burden of Prior Authorizations

October 8, 2018 - Prior authorizations, or prior approvals, are strategies that payers use to control costs and ensure their members only receive medically necessary care. The cost-control process requires providers to acquire advance approval from payers before delivering specific services or items for a patient. Payers are increasingly using prior authorizations to lower their costs and improve care...


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Medicare Advantage Plans Overturn 75% of Their Own Claim Denials

by Jacqueline LaPointe

A new report from the HHS Office of the Inspector General (OIG) reveals “widespread and persistent problems” related to prior authorization and claim denials in Medicare Advantage. Using Medicare Advantage data on denials,...

RCCH Uses Predictive Analytics to Boost Claim Denials Management

by Jacqueline LaPointe

Predictive analytics are key to implementing an effective and efficient claim denials management strategy that tackles the right denials at the right time, according to the Vice President of Revenue Cycle at Tennessee’s RCCH...

When Claims Reimbursement Doesn’t Cover Healthcare Innovation

by Jacqueline LaPointe

Implementing healthcare innovations that improve care quality is key to boosting patient experience and care quality, but what happens when claims reimbursement doesn’t cover the use of the latest and greatest services? This is the...

HHS to Clear Medicare Appeals Backlog by 2022, Court Docs Show

by Jacqueline LaPointe

HHS is making significant progress with eliminating the growing Medicare appeals backlog, according to recent court documents. The federal department projects Medicare to clear the backlog by the 2022 fiscal year. A 70 percent increase in...

Medicaid Could Save $4.8B Through Electronic Claims Management

by Jacqueline LaPointe

State Medicaid programs are significantly lagging with the adoption of fully electronic claim submissions, claim reimbursements, prior authorizations, and other claims management processes, according to a new Council for Affordable Quality...

CAQH Stresses the Importance of Prior Authorization Automation

by Jacqueline LaPointe

CAQH’s Committee on Operating Rules for Information Exchange (CORE) is urging a group of industry leaders to encourage prior authorization automation as part of their efforts to improve the entire prior authorization process. The...

Healthcare Claims Management Market to Reach $13.9B by 2023

by Jacqueline LaPointe

The global healthcare claims management market is slated to reach $13.93 billion by 2023, up from a valuation of $10.16 billion in 2017, MarketsandMarkets recently reported. The significant projected growth in the healthcare claims...

Electronic Claims Management Adoption Could Save Providers $9.5B

by Jacqueline LaPointe

Transitioning from manual to fully electronic claims management would save the healthcare industry $11.1 billion annually, with providers seeing the greatest share of the savings, the fifth annual CAQH Index found. Providers would save...

CMS Proposes New Pre-Claim Review for Home Health Agencies

by Jacqueline LaPointe

CMS is floating the idea of implementing another pre-claim review of Medicare claims submitted by home health agencies in at least five states, according to a recent notice of proposed information collection. The federal agency proposed...

Hospitals Wait 16 More Days for Late Payments from Claim Denials

by Jacqueline LaPointe

Delayed payments stemming from claim denials are significantly impacting hospital revenue cycles, taking an average 16.4 more days to pay compared to claims that have not been denied, a new analysis from Crowe Horwath revealed. The...

Medical Billing Complexity Highest for Medicaid Fee-for-Service

by Jacqueline LaPointe

Medical billing for Medicaid fee-for-service claims proved to be the most complex across all insurers. The public payer had a claims denial rate 17.8 percentage points greater than the rate for Medicare fee-for-service claims, a new Health...

Bringing Profee, Facility Together to Maximize Coding Productivity

by Jacqueline LaPointe

Professional and facility coding describe two very different aspects of a healthcare. But breaking down the wall between the departments has the potential to boost coding productivity and improve clean claim rates. While professional...

92% of Docs Say Prior Authorizations Negatively Impact Outcomes

by Jacqueline LaPointe

Physicians are reporting that prior authorizations are negatively affecting patient care, a new American Medical Association (AMA) survey of 1,000 physicians showed. Ninety-two percent of primary care and specialty physicians who provide...

CMS Guidance to Lower Claim Denials for Inpatient Rehab Facilities

by Jacqueline LaPointe

CMS recently clarified that contracted auditors should not give inpatient rehabilitation facilities claim denials solely because the services did not meet time-based therapy requirements. The guidance, which will go into effect on March...

AMA, Anthem Team Up to Streamline Prior Authorizations

by Jacqueline LaPointe

The American Medical Association (AMA) and Anthem, Inc. recently announced that they will work together over the next year to streamline prior authorization requirements and improve the healthcare experience overall through provider and...

CMS Opens Low Volume Appeals Settlement to Reduce Appeals Backlog

by Jacqueline LaPointe

In the face of a growing Medicare appeals backlog, CMS opened the first round of a low volume appeals settlement on Feb. 5 for providers with less than 500 claim denial appeals stuck in the appeals backlog at the Office of Medicare...

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