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

Claims Processing

Bots Make Claim Status Inquiry More Efficient for Avera Health

February 20, 2019 - Robots in healthcare do not have to be large human-like machines that replace providers. But bots embedded in software applications can be a key tool for reducing the burden of mundane, common tasks, such as claim status inquiry. At least that is what Mary Wickersham, Vice President of Central Business Office Operations at Avera Health in the upper Midwest found after implementing a...


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3 Strategies to Minimize the Burden of Prior Authorizations

by Jacqueline LaPointe

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...

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...

CAQH CORE Opens Certification for Electronic Prior Authorization

by Jacqueline LaPointe

CAQH’s Committee on Operating Rules for Information Exchange (CAQH CORE) recently opened the certification process for Phase IV operating rules, which include standard rules for the electronic exchange of administrative data, such as...

Medicare Appeals Backlog Delays Decision Process By 4.5 Years

by Jacqueline LaPointe

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...

3 Best Practices for Hospital Claim Denials Management

by Jacqueline LaPointe

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...

CMS Pauses Home Health Pre-Claim Review Demonstration

by Jacqueline LaPointe

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,...

Top 4 Claims Denial Management Challenges Impacting Revenue

by Jacqueline LaPointe

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...

AMA: Eliminate Prior Authorization for Opioid Abuse Treatment

by Jacqueline LaPointe

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...

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...

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...

5 Claims Denials Management Conversations From 2015

by Jacqueline DiChiara

This year, the healthcare industry lived in denial. Claims denial, that is. Claims denials management dialogues were extensive and recurring among healthcare providers across the industry this year.  Here are 5 claims...

Safeguards possibly ineffective on some copayment coupons

by Elizabeth Snell

Pharmaceutical manufacturers’ current safeguards may not prevent all copayment coupons from being used for drugs paid for by Part D, according to a recent Office of Inspector General (OIG) report. The coupons are typically offered...

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