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

Claims Management

$262B of Total Hospital Charges in 2016 Initially Claim Denials

June 26, 2017 - Approximately 9 percent of hospital charges in 2016 were initially claim denials, according to a new Change Healthcare study. As a result, $262 billion out of $3 trillion in claims submitted last year was denied. The analysis of over 3.3 billion provider transactions from about 724 hospitals in 2016 also revealed that as much as 3.3 percent of net patient revenue at the typical health system...

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86% of Providers Saw Prior Authorization Requirements Increase

by Jacqueline Belliveau

Approximately 86 percent of medical practice leaders reported that prior authorization requirements have increased over the past year, a recent MGMA survey of over 1,000 leaders found. Only 3 percent stated that prior authorization requirements...

Medicare Appeals Backlog Delays Decision Process By 4.5 Years

by Jacqueline Belliveau

Hospitals waited an average of 1,663.3 days, or a little over 4.5 years, to conclude the Medicare reimbursement audit and appeals process because of the extensive Medicare appeals backlog, a recent Journal of Hospital Medicine study uncovered....

3 Best Practices for Hospital Claim Denials Management

by Jacqueline Belliveau

Healthcare cost control continued to top hospital priority lists in 2017. But hospital leaders may be leaving millions of dollars on the table because of inefficient claim denials management processes. Claim denial rates ranged between 0.54 percent...

CMS Pauses Home Health Pre-Claim Review Demonstration

by Jacqueline Belliveau

CMS recently halted the home health Pre-Claim Review demonstration in Illinois for 30 days and the program will not expand to Florida as expected in April 2017, according to the federal agency’s website. “After March 31, 2017, and...

Top 4 Claims Denial Management Challenges Impacting Revenue

by Jacqueline Belliveau

For most healthcare organizations, claim denials are a normal, if not a frequent, occurrence. While very few can boast that their denial rates are close to zero, many providers face a number of challenges with implementing an effective claims...

Payer, Provider Dialogue Key to Prior Authorization Reform

by Jacqueline Belliveau

ORLANDO - Prior authorization reform has recently been a hot topic for many healthcare industry groups and it was no different at HIMSS17. To find out more about what providers and payers plan on doing to alleviate the administrative and care...

AMA: Eliminate Prior Authorization for Opioid Abuse Treatment

by Jacqueline Belliveau

The American Medical Association (AMA) recently called on attorney generals across the nation to follow in New York’s footsteps with reforming prior authorization requirements for medication-assisted treatment for opioid abuse. New York’s...

Healthcare Groups Offer 21 Prior Authorization Improvements

by Jacqueline Belliveau

A coalition of 17 healthcare industry groups recently called on health plans, benefit managers, and other healthcare stakeholders to change prior authorization requirements to improve care continuity, reduce provider burdens, and improve timely...

HHS Finalizes Solutions to Decrease Medicare Appeals Backlog

by Jacqueline Belliveau

In effort to reduce the significant Medicare appeals backlog, the Department of Health and Human Services (HHS) recently finalized several appeals process changes. Major modifications included using precedential decision-making at the Departmental...

CMS Brings Integrated, Multi-Payer Claims Data Access to CPC+

by Jacqueline Belliveau

In an official blog post, CMS recently touted its success with improving primary care provider productivity by giving practices in the Comprehensive Primary Care (CPC) program more multi-payer claims data access. The Medicare primary care program...

Electronic Claims Management Adoption to Save Providers $7.9B

by Jacqueline Belliveau

Healthcare providers could save about $7.9 billion annually by switching to automated claims management processes, particularly for prior authorizations, remittance advices, and claim attachment submissions, according to the 2016 CAQH Index....

Court Denies HHS Wish to Nix Medicare Appeals Backlog Timeline

by Jacqueline Belliveau

A federal court recently denied a Department of Health and Human Services (HHS) request to reconsider the four-year timeline developed to eliminate the Medicare appeals backlog at the administrative law judge level. HHS projected the backlog...

Judge Calls for Medicare Appeals Backlog Elimination by 2020

by Jacqueline Belliveau

The Department of Health and Human Services (HHS) must eliminate the Medicare appeals backlog at the administrative law judge review level by Dec. 31, 2020, a federal judge recently decided. The most recent decision ends a two-and-a-half-year...

CMS Offers 66% Settlement to Reduce Medicare Appeals Backlog

by Jacqueline Belliveau

In an effort to resolve the Medicare appeals backlog, CMS recently reopened a settlement option that would allow hospitals to receive partial reimbursement for some claim denials currently stuck in the appeals process. Similar to the 2014 settlement...

CMS Launches Provider Engagement, Value-Based Care Initiative

by Jacqueline Belliveau

CMS recently announced a new provider engagement initiative designed to improve the clinician experience within the Medicare program, especially as value-based care models are developed under the Affordable Care Act and MACRA. As alternative...

Using Data Analytics to Decrease Claims Denials, Boost Revenue

by Jeff Wood

Claims denials typically represent one of the largest revenue cycle bottlenecks in most healthcare organizations.  However, slowing down to determine why claims are being denied hasn’t traditionally been an option. The light at the...

31% of Providers Still Use Manual Claims Denial Management

by Jacqueline Belliveau

As the transition to value-based care carries on, many healthcare providers are reexamining their current healthcare revenue cycles to account for new alternative payment models. With providers experiencing an increase in claims denials and denial...

Why Claims Accuracy Testing, QA Isn’t Working for Healthcare

by Mark Benedict

Let’s face it. Testing isn’t working.  That’s the hard truth about the healthcare industry and its track record on claims accuracy testing and quality assurance. The harder truth is that this problem is expensive –...

What Are the Front-End Steps of Revenue Cycle Management?

by Jacqueline DiChiara

Revenue cycle management is the progression of events between when a patient makes a doctor’s appointment and when a patient’s money is received and reimbursed for following care delivery. When a service has been fully paid...


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