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

Healthcare Payers

Social Determinants of Health Key to Value-Based Purchasing Success

January 9, 2019 - We are quickly heading to the value-based purchasing tipping point, according to the Vice President of Network Management at Health Partners Plans in Pennsylvania. “While adoption rates are still relatively low in some regions of the country, almost all health plans and providers are doing work in this space and the percentage of spending in the value-based care space will...


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Key Providers, Payers Tie 47% of Business to Value-Based Payment

by Jacqueline LaPointe

A large group of major healthcare payers and health systems are reporting that nearly half of their business rests in value-based payment arrangements. The Health Care Transformation Task Force (Task Force) is a group of leading...

Provider Directory Accuracy Issues Persist for Medicare Advantage

by Jacqueline LaPointe

Online Medicare Advantage provider directories are still not accurate, according to a recent CMS analysis of approximately one-third of Medicare Advantage Organizations (MAOs). In its third round of online provider directory reviews, CMS...

DoJ Offers Insight into Anti-Steering, Antitrust Case with Atrium

by Jacqueline LaPointe

The Department of Justice (DoJ) is shedding more light on its recent settlement with North Carolina-based Atrium Health over allegations the health system used its market power to create anti-competitive contracts with private...

Atrium Health Settles Anticompetitive Hospital Contracting Claims

by Jacqueline LaPointe

Atrium Health in North Carolina recently agreed to a settlement with the Department of Justice (DoJ) and the North Carolina Office of Attorney General that prohibits the health system from using anticompetitive hospital contracting terms...

Investing in Primary Care Delivers Value-Based Care Results

by Jacqueline LaPointe

Supporting primary care will bring value-based care results, asserts Humana’s Chief Medical Officer Roy Beveridge, MD. Value-based arrangements between providers and payers have the lofty, yet admirable goals of improving care...

AHA: Consolidated Payer Market Influences Hospital Contracting

by Jacqueline LaPointe

“The overwhelming majority of hospitals and health systems are not the drivers in contract negotiations with commercial health insurers,” the American Hospital Association (AHA) recently said in response to a potential FTC...

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...

Artificial Intelligence Ensures Payer, Provider Pay Covers Costs

by Jacqueline LaPointe

Artificial intelligence (AI) in healthcare is influencing the next generation of radiology tools and helping to expand access to care in underserved or developing areas. The technology is supporting clinical advancements, but a...

Ascension, Centene Partner to Launch Medicare Advantage Plan

by Jacqueline LaPointe

The nation’s largest non-profit health system, Ascension, and health payer Centene Corporation are teaming up to launch a Medicare Advantage plan in multiple markets, the organizations recently announced in a joint statement. The...

Industry Orgs Fight Anthem’s Emergency Department Payment Policy

by Jacqueline LaPointe

The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) are suing Anthem’s Blue Cross Blue Shield (BCBS) of Georgia over a new policy that allows the payer to retroactively deny emergency...

Key Terms, Components of Payer Contracts Providers Should Know

by Jacqueline LaPointe

Providers are in the business of keeping their patients healthy. But confusing payer contracts riddled with “legalese” and other complicated provisions can get in the way of improving patient outcomes. Payer contracts define...

Provider Data Standardization Critical to Improving Inaccuracies

by Jacqueline LaPointe

A multi-disciplinary workgroup is calling for provider data standardization to ensure accurate provider information is available for connecting patients with providers, licensing providers, and paying for services. The Provider Data...

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...

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...

Docs Call for Provider Directory Accuracy to Improve Care Access

by Jacqueline LaPointe

Over one-half (52 percent) of physicians reported that their patients faced coverage issues at least once a month because of provider directory accuracy challenges, revealed a new survey from the American Medical Association (AMA) and...

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...

Provider Data Integrity Key to Directory Accuracy, Value-Based Care

by Jacqueline LaPointe

Providers and their payers oftentimes have a love-hate relationship. Payers boost the number of patients walking through physician office doors using provider directories as well as reimburse providers for treating those patients. But...

Does Where Freestanding EDs Operate Change Hospital Payer Mix?

by Jacqueline LaPointe

Freestanding emergency departments (EDs) may be altering the payer mix at the equivalent hospital-based facility because the freestanding EDs tend to be located in areas with greater household incomes and insured rates, stated a recent...

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