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

Denials Management

AMA: Health Payers Lagging with Prior Authorization Reform

March 14, 2019 - 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 national association recently surveyed 1,000 practicing physicians to gauge the healthcare industry’s progress with prior authorization reforms agreed upon in the “Consensus Statement...


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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 claims clearinghouse vendor. Vibra...

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 (PAC) process, and in conjunction with...

Court Orders HHS to Eliminate Medicare Appeals Backlog by 2022

by Jacqueline LaPointe

HHS must eliminate the Medicare appeals backlog at the Administrative Law Judge (ALJ) level by the end of the 2022 fiscal year, according to a recent court order. Judge James E. Boasberg of the US District Court for the District of...

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...

Medicare Advantage Plans Overturn 75% of Their Own Claim Denials

by Jacqueline LaPointe

A new report from the HHS Office of the Inspector General (OIG) reveals “widespread and persistent problems” related to prior authorization and claim denials in Medicare Advantage. Using Medicare Advantage data on denials,...

RCCH Uses Predictive Analytics to Boost Claim Denials Management

by Jacqueline LaPointe

Predictive analytics are key to implementing an effective and efficient claim denials management strategy that tackles the right denials at the right time, according to the Vice President of Revenue Cycle at Tennessee’s RCCH...

HHS to Clear Medicare Appeals Backlog by 2022, Court Docs Show

by Jacqueline LaPointe

HHS is making significant progress with eliminating the growing Medicare appeals backlog, according to recent court documents. The federal department projects Medicare to clear the backlog by the 2022 fiscal year. A 70 percent increase in...

CMS Proposes New Pre-Claim Review for Home Health Agencies

by Jacqueline LaPointe

CMS is floating the idea of implementing another pre-claim review of Medicare claims submitted by home health agencies in at least five states, according to a recent notice of proposed information collection. The federal agency proposed...

Expanded Resolution Process Opens to Lower Medicare Appeals Backlog

by Jacqueline LaPointe

HHS recently announced an expanded alternative dispute resolution process that aims to reduce the growing Medicare appeals backlog. The expanded Settlement Conference Facilitation (SCF) process promises to streamline Medicare dispute...

69% of Hospitals Use Multiple Vendors for Revenue Cycle Management

by Jacqueline LaPointe

Almost 69 percent of healthcare organizations use more than one vendor solution for revenue cycle management. However, these organizations tended to have more problems with claim denials management, a recent Dimensional Insight and HIMSS...

Hospitals Wait 16 More Days for Late Payments from Claim Denials

by Jacqueline LaPointe

Delayed payments stemming from claim denials are significantly impacting hospital revenue cycles, taking an average 16.4 more days to pay compared to claims that have not been denied, a new analysis from Crowe Horwath revealed. The...

Judge Asks AHA to Develop Medicare Appeals Backlog Solutions

by Jacqueline LaPointe

A federal judge is calling on the American Hospital Association (AHA) to recommend strategies to reduce the growing Medicare appeals backlog, a recent court order stated. According to the AHA’s website, US District Judge James...

Medical Billing Complexity Highest for Medicaid Fee-for-Service

by Jacqueline LaPointe

Medical billing for Medicaid fee-for-service claims proved to be the most complex across all insurers. The public payer had a claims denial rate 17.8 percentage points greater than the rate for Medicare fee-for-service claims, a new Health...

Bringing Profee, Facility Together to Maximize Coding Productivity

by Jacqueline LaPointe

Professional and facility coding describe two very different aspects of a healthcare. But breaking down the wall between the departments has the potential to boost coding productivity and improve clean claim rates. While professional...

92% of Docs Say Prior Authorizations Negatively Impact Outcomes

by Jacqueline LaPointe

Physicians are reporting that prior authorizations are negatively affecting patient care, a new American Medical Association (AMA) survey of 1,000 physicians showed. Ninety-two percent of primary care and specialty physicians who provide...

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...

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...

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...

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