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

Denials Management

CMS Proposes New Pre-Claim Review for Home Health Agencies

June 1, 2018 - 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 that home health agencies would have the option of demonstrating their compliance with Medicare reimbursement policies through either pre-claim or...


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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...

Real-Time Data for Denials Management Aids Practice’s Lagging A/R

by Jacqueline LaPointe

Without transparency throughout the claim denials management process, healthcare organizations are leaving a significant portion of potential revenue on the table. Limited access to timely claim denial and reimbursement data can prevent...

Court to Reconsider Timeline for Medicare Appeals Backlog End

by Jacqueline LaPointe

The DC appeals court recently revoked the court-ordered elimination timeline for the current $6.6 billion Medicare appeals backlog, arguing that the previous court was in error of the law by requiring HHS to do away with the backlog...

$262B of Total Hospital Charges in 2016 Initially Claim Denials

by Jacqueline LaPointe

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...

86% of Providers Saw Prior Authorization Requirements Increase

by Jacqueline LaPointe

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...

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...

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