Claims Management

Providers Highly Value Revenue Integrity, Underpayment Firms

by Samantha McGrail

Revenue integrity and underpayment firms are helping organizations recoup lost revenue and prevent future losses, bringing value to provider organizations, KLAS recently reported.  In a new...

Providers Ready for AI Clinical Documentation Improvement Tools

by Jacqueline LaPointe

Forty-four percent of healthcare organizations already use artificial intelligence (AI) in one form or another, and more hospitals are looking to apply the technology to coding and clinical...

HHS Ahead of Schedule for Eliminating Medicare Appeals Backlog

by Jacqueline LaPointe

HHS reduced the Medicare appeals backlog at the administrative law judge level by 25 percent through the third quarter of fiscal year (FY) 2019, according to a recent status report obtained by the...

370 Groups Seek Prior Authorization Automation, Reform in MA

by Jacqueline LaPointe

The American College of Rheumatology (ACR), along with 369 other patient, physician, and healthcare professional organizations, sent a letter to Congress on Wednesday calling for prior authorization...

6 Challenges of End-to-End Automation for Prior Authorizations

by Jacqueline LaPointe

Only 12 percent of the 182 million medical sector prior authorization transactions were fully electronic in 2018, making prior authorizations one of the most manual transactions compared to other...

Hospitals Call for Medical Billing, Prior Authorization Reform

by Jacqueline LaPointe

CMS recently called on industry stakeholders to suggest ways that the agency can reduce administrative burdens, and hospitals did not disappoint. The federal agency received over 560 comments in...

CMS Seeks Electronic Prior Authorization for Medicare Part D Drugs

by Jacqueline LaPointe

CMS recently issued a proposed rule that aims to significantly reduce provider burden by implementing electronic prior authorization for medications prescribed through Medicare Part D. Specifically,...

How Advocate Aurora Health Streamlined Prior Authorizations

by Jacqueline LaPointe

Prior authorizations used to be one of the greatest pain points for providers at Advocate Aurora Health. While most physicians recently surveyed by the American Medical Association (AMA) said they...

Interoperability Reform Should Boost Claims Data Access, AMGA Says

by Jacqueline LaPointe

Increased claims data access for providers should be at the heart of new interoperability standards and requirements, AMGA recently stressed in comment letters on two proposed rules from CMS and the...

Using Artificial Intelligence to Advance Revenue Cycle Management

by Jacqueline LaPointe

Artificial intelligence (AI) is making big waves in healthcare from detecting lung cancer and gene mutations that lead to autism to addressing social determinants of health and chronic conditions. The...

CAQH CORE Creates New Rules for Prior Authorization Automation

by Jacqueline LaPointe

CAQH’s Committee on Operating Rules for Information Exchange (CORE) recently released Phase V operating rules to move the healthcare industry toward full prior authorization automation. The new...

CMS Ditches Signatures to Improve Medicare Appeals Process

by Jacqueline LaPointe

CMS recently finalized a rule that aims to streamline the Medicare appeals process and reduce provider burden by eliminating signature requirements for appeal requests. The rule published on May 7...

Recovery Audit Contractor Reform Eases Provider Burden, CMS Says

by Jacqueline LaPointe

The Medicare fee-for-service Recovery Audit Contractor (RAC) program found approximately $89 million in overpayments and recovered $73 million in the fiscal year (FY) 2018, CMS Administrator Seema...

Insurance and Medical Billing Costs for Providers Reaches $282B

by Jacqueline LaPointe

Providers and payers spend about $496 billion on insurance and medical billing costs, with about one-half of the costs being excessive, reveals a new issue brief from the independent policy institute,...

AMA: Health Payers Lagging with Prior Authorization Reform

by Jacqueline LaPointe

Health payers have not made meaningful progress with prior authorization reform, the American Medical Association (AMA) recently argued following the release of their new physician survey. The...

Rethinking the Claims Clearinghouse Relationship Helps Hospitals

by Jacqueline LaPointe

A growing network of post-acute care hospitals based in Pennsylvania recently achieved a near perfect clean claims rate and uncovered $12 million in inappropriate payer denials after switching its...

EHR Vendor Help Needed for Prior Authorization Improvement

by Jacqueline LaPointe

The Workgroup for Electronic Data Interchange (WEDI) will be calling on the EHR vendor community for prior authorization improvement. “Based upon the findings of the Prior Authorization Council...