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

Denials Management

3 Strategies to Minimize the Burden of Prior Authorizations

October 8, 2018 - 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 before delivering specific services or items for a patient. Payers are increasingly using prior authorizations to lower their costs and improve care...


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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...

Private Payer A/R, Denials Performance Troubles Hospital Revenue

by Jacqueline LaPointe

Small differences in private payer performance on claims reimbursement and denials can challenge hospital revenue cycles, a new Crowe Horwath analysis of five major commercial managed care payers uncovered. “Many providers focus...

Hospitals Write Off 90% More Claim Denials, Costing up to $3.5M

by Jacqueline LaPointe

Hospitals strengthened key revenue cycle components over the past two years, but claims denials represented a major threat to their financial health, the recent Revenue Cycle Survey from Advisory Board revealed. Health systems and...

KLAS: Quadax, SSI Group Earn Top Scores for Claims Management

by Jacqueline LaPointe

Respondents in a recent KLAS report named Quadax, SSI Group, and ZirMed as the best overall performing claims management vendors because of the high-quality customer service and support provided by the companies. The 296 healthcare...

AHA: OIG Hospital Audit Extrapolation Led to Excessive Claim Denials

by Jacqueline LaPointe

The American Hospital Association (AHA) recently urged CMS to reconsider its extrapolation approach when conducting Office of the Inspector General (OIG) hospital audits because the method leads to excessive repayment requests and claim...

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