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

Claims Reimbursement

340B Hospitals Delivered $26B in Unreimbursed, Uncompensated Care

by Jacqueline LaPointe

Unreimbursed and uncompensated care costs were 27.4 percent higher at Disproportionate Share Hospitals (DSH) enrolled in the 340B Drug Pricing Program in 2015 compared to non-340B acute care hospitals, according to a new analysis from...

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...

Judge Voids CMS Rule Altering Medicaid DSH Payment Calculations

by Jacqueline LaPointe

A US District Court for Washington DC recently vacated a CMS final rule from 2017 that required third-party payments, including those from Medicare, to be used when calculating hospital-specific limits on Medicaid Disproportionate Share...

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...

AHA, Hospital Groups Renew Call to End 340B Drug Payment Cuts

by Jacqueline LaPointe

After a federal judge recently ruled that CMS can enforce cuts to 340B drug payments, the American Hospital Association (AHA) and 35 state and regional hospital associations resumed their efforts to end $1.6 billion in reimbursement...

Slow and Steady Still the Motto for Value-Based Reimbursement

by Jacqueline LaPointe

The healthcare industry has boarded the train to value-based reimbursement. But recent roadblocks have provider organizations pumping the brakes with the shift away from fee-for-service, explained industry experts Doral Jacobsen, MBA,...

MO Court Bans CMS from Altering DSH Medicaid Reimbursement Rules

by Jacqueline LaPointe

A District Court in Missouri prohibited CMS from enforcing a 2017 final rule and two Frequently Asked Questions (FAQs) from 2010 that would alter the formula for calculating hospital-specific limits for  Medicaid reimbursement under...

Hospital Cost-Shifting Increases Private Payer Payments by 1.6%

by Jacqueline LaPointe

Healthcare organizations that faced Medicare reimbursement reductions under the Affordable Care Act engaged in hospital cost-shifting that resulted in 1.6 percent higher average payments from private payers, a new working paper from the...

Medicare Wellness Visit Adoption Boosts Primary Care Revenue

by Jacqueline LaPointe

Practices that performed Medicare wellness visits on at least a quarter of their patients earned greater primary care revenue, experienced more patient assignment stability, and treated patients who were slightly healthier, a new Health...

How the Bipartisan Budget Act of 2018 Impacts Claims Reimbursement

by Jacqueline LaPointe

After facing two government shutdowns this year, Congress passed a long-term budget deal and President Trump signed it into law early on Feb. 9, 2018. While the Bipartisan Budget Act of 2018 included plans for avoiding another shutdown 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...

85% of Hospitals to See Part B Increase Despite 340B Payment Cuts

by Jacqueline LaPointe

EDITOR'S NOTE: This article has been updated with a statement from the American Hospital Association. Approximately 85 percent of hospitals will receive a net increase in their total Medicare Part B reimbursements despite recent...

AHA, AMA and Others Offer 5 Prior Authorization Reform Strategies

by Jacqueline LaPointe

Six industry groups representing providers, payers, and pharmacists recently partnered to identify strategies to improve prior authorization processes, such as decreasing the number of providers subject to prior authorizations and...

Reimbursement Shortfalls, Uncompensated Care Costs Grew in 2016

by Jacqueline LaPointe

Medicaid and Medicare reimbursement in 2016 was $68.8 billion short of actual hospital costs for treating beneficiaries, according to data from the American Hospital Association (AHA). The information from the AHA’s Annual Survey of...

Judge Denies Hospital Org Attempt to Block 340B Drug Payment Cut

by Jacqueline LaPointe

A federal judge recently ruled that CMS can start to reduce 340B drug payments to hospitals by $1.6 billion starting on Jan. 1, 2018, striking a blow to several industry groups that urged the court to delay enforcement of the new rule. US...

AHA Opposes Medicare Reimbursement Cut for Early Hospice Care

by Jacqueline LaPointe

Congress should not pass a proposed policy to reduce Medicare reimbursement rates to hospitals discharging patients to hospice care earlier than the expected, the American Hospital Association (AHA) advised. The proposed policy builds on...

Healthcare RCM, Medicare Reimbursement Dominate 2017 Stories

by Jacqueline LaPointe

From the Quality Payment Program’s launch to the Affordable Care Act debate, the healthcare finance world saw an abundance of change and uncertainty in 2017. In the face of payment reform and political debates, healthcare leaders...

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...

Family Physicians Slowly Embracing Value-Based Reimbursement

by Jacqueline LaPointe

Slightly more family physicians are actively pursuing value-based reimbursement opportunities compared to two years ago despite persistent barriers, Humana and the American Academy of Family Physicians (AAFP) recently announced. The...

Medical Billing Codes Do Not Address Full Scope of Primary Care

by Jacqueline LaPointe

Current Procedural Terminology (CPT) codes used for medical billing did not account for all the care provided by primary care physicians in about 60.3 percent of visits, a recent Journal of the American Board of Family Medicine study...

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