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

Claims Reimbursement

$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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Limited Healthcare Payment Incentives Challenge Care Management

by Jacqueline Belliveau

Misaligned healthcare payment incentives topped the list of challenges providers and payers faced when implementing effective care management programs under Medicare Advantage plans with capitated payments, a recent Robert Graham Center for Policy...

Optimizing RCM During Value-Based Reimbursement Transition

by Jacqueline Belliveau

Value-based reimbursement revolutionized how providers get paid for care delivery. However, the slow push away from fee-for-service payments has challenged providers looking to optimize healthcare revenue cycle management. To advance healthcare...

AHA Calls For 25% Rule End for Fair LTCH Medicare Reimbursement

by Jacqueline Belliveau

The American Hospital Association (AHA) pressed CMS Administrator Seema Verma to reconsider proposed Medicare reimbursement provisions for long-term care hospitals (LTCHs). Specifically, the industry group called for a permanent end to the 25-Percent...

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...

2016 Medicaid, Medicare Improper Payments Over Regulatory Cap

by Jacqueline Belliveau

A recent Office of the Inspector General (OIG) report revealed that the rates of Medicaid and Medicare improper payments in 2016 exceeded the legislative threshold of less than 10 percent. The improper payment rate for Medicare fee-for-service...

AHA Urges Rural, Post-Acute Care Medicare Reimbursement Reform

by Jacqueline Belliveau

In a Congressional hearing on the current status of Medicare reimbursement systems, the American Hospital Association (AHA) urged lawmakers to focus on rural hospital and post-acute care payments. MACRA extended a number of key Medicare reimbursement...

Execs Say Value-Based Purchasing to Hit Tipping Point by 2020

by Jacqueline Belliveau

Over one-half (55 percent) of healthcare executives surveyed after the recent presidential election stated that the industry should reach the value-based purchasing tipping point before 2020, a recent Lazard report revealed. The survey of 203...

Will Behavioral Economics Improve Alternative Payment Models?

by Jacqueline Belliveau

Alternative payment models may need to account for the behavioral economics behind provider prescribing habits to effectively reduce healthcare costs from expensive medications and treatments, a recent American Journal of Managed Care study stated....

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...

AMGA: Align Medicare Reimbursement, Measures for High-Value Care

by Jacqueline Belliveau

AMGA recently called on CMS to align quality measures with spending performance as well as Medicare reimbursement policies across Medicare Advantage, fee-for-service models, and accountable care organizations (ACOs). In two letters to CMS Acting...

CMS Suggests Hospital Medicare Reimbursement Policy Changes

by Jacqueline Belliveau

CMS recently suggested changes to Medicare reimbursement policies for hospital admissions and long-term care hospital stays as well as several recommendations for other Medicare value-based purchasing programs. The proposed rule released on April...

TN Law Aims to Make Payer Contract Management More Predictable

by Jacqueline Belliveau

Earlier this week, Tennessee Governor Bill Haslam signed the Provider Stability Act into law, which intends to increase transparency and accountability for payer contract management. Effective Jan. 1, 2019, the law will require payers in the...

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...

AMGA Supports 15% Limit for Medicare Advantage Encounter Data

by Jacqueline Belliveau

AMGA recently applauded CMS for further reducing the percentage of encounter data to be used to determine Medicare Advantage enrollee risk scores from 25 percent in the proposed rule to 15 percent in the final 2018 performance year update. “It...

AHA: Post-Acute Care Medicare Reimbursement Reform Needs Time

by Jacqueline Belliveau

Later this month, the Medicare Payment Advisory Commission (MedPAC) plans to vote on a draft recommendation to Congress that would accelerate the development and implementation of a unified Medicare reimbursement system for four post-acute care...

Oncologist Org Opposes MedPAC Medicare Reimbursement Changes

by Jacqueline Belliveau

The Community Oncology Alliance (COA) recently expressed concerns that proposed Medicare reimbursement changes for Part B services from the Medicare Payment Advisory Commission (MedPAC) would drive cancer care to more higher-cost settings. “MedPAC...

MedPAC Targets Post-Acute Care for Healthcare Payment Reform

by Jacqueline Belliveau

In its March 2017 report to Congress, the Medicare Payment Advisory Commission (MedPAC) pinpointed post-acute care for healthcare payment reform after Congressional and CMS inaction resulted in as much as $11 billion in lost savings since 2009....

Using Bundled Payments to Pay Providers for mHealth Nudges

by Jacqueline Belliveau

Many providers have been able to extend their reach outside of their office by using mHealth technologies that encourage patients to improve their own health outcomes through nudges. However, payment structures for the healthcare encounters have...

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