Claims reimbursement
Providers rely on payer reimbursement to cover the costs of providing healthcare services. Without timely and complete reimbursement, providers may struggle to maintain operations. Effective claims management helps to reduce errors and minimize fraud risk while streamlining the reimbursement process to decrease denials.
Top Stories
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11 Sep 2024
AMA 2025 CPT code set updates focus on novel genetic testing
The AMA's 2025 CPT code set has 420 updates, including new codes for genetic testing, AI medical services, remote therapeutic monitoring and novel surgical techniques. Continue Reading
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04 Sep 2024
Hospital finances are stabilizing, Kaufman Hall data finds
Hospital finances continue to stabilize with a 3.8% operating index in July 2024, driven by increased outpatient revenue and shorter stays, according to recent Kaufman Hall data. Continue Reading
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30 Jul 2024
Providers offer 4 key payment reforms to support practices
AMA and other provider trade groups have urged Congressional leaders to reform physician payment in light of recent Medicare cuts. Continue Reading
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22 Jul 2024
AMA updates CPT code set for avian influenza vaccines
The update to the CPT code set includes codes for vaccines protecting patients from the H5N8 strain of avian influenza. Continue Reading
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09 Jul 2024
DoJ catches over $2.7B in healthcare fraud schemes
The Department of Justice has charged nearly 200 people, including doctors, in over $2.7B in healthcare fraud schemes. Continue Reading
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02 Jul 2024
Medicare home health payments to dip 1.7% in CY 2025
A new proposed rule would decrease Medicare home health payments by 1.7%, or $280M, next calendar year as CMS finalizes a permanent behavior adjustment. Continue Reading
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24 Jun 2024
Prior authorizations often denied, adding to provider burden
The latest prior authorization survey from the AMA shows a high administrative burden associated with the management tool and patient care consequences. Continue Reading
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17 Jun 2024
Exploring the role of medical claim clearinghouses
Medical claim clearinghouses manage claim submissions for providers, increasing efficiency, reducing costs and improving payment accuracy. Continue Reading
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13 Jun 2024
National healthcare spending grows 7.5% to nearly $4.8T
National healthcare spending continued to grow in 2023 with more people insured and the higher price of personal healthcare, CMS actuaries report. Continue Reading
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12 Jun 2024
Supreme Court agrees to review Medicare DSH case
The Supreme Court will accept a case that seeks greater clarity on how HHS calculates Medicare DSH payments to hospitals. Continue Reading
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Feature
10 Jun 2024
Unpacking the mid-revenue cycle, strategies for success
The mid-revenue cycle includes coding, CDI, and compliance, making its processes vital to a provider organization’s success. Continue Reading
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30 May 2024
RAND: Hospital prices 254% higher than Medicare rates
The latest RAND Corporation analysis of hospital prices finds that employers and private payers paid significantly more than Medicare for the same services at the same facilities. Continue Reading
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20 May 2024
Senate Finance contemplates physician payment reform
A new Senate Finance Committee white paper lays out opportunities for Medicare Physician Fee Schedule reform to improve chronic care and value. Continue Reading
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16 May 2024
Physician practices earned large financial bonuses under BPCI-A
A new study finds that CMS paid $421M in bonuses to physician practices participating in BPCI-A, with higher target prices leading to larger bonuses. Continue Reading
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09 May 2024
Public, not nonprofit hospitals use 340B to expand services
A new JAMA study finds participation in the 340B Drug Pricing Program helps public but not nonprofit hospitals to sustain unprofitable service lines. Continue Reading
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03 May 2024
Machine learning algorithm improved risk adjustment models, study finds
The machine learning algorithm helped avoid significant underpayments for people with at least one rare diagnosis. Continue Reading
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12 Apr 2024
OIG: Improve Medicare rate-setting for clinical diagnostic lab tests
The federal watchdog OIG is urging CMS to improve Medicare rate-setting for clinical diagnostic lab tests to better prepare for future public health emergencies. Continue Reading
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11 Apr 2024
CMS proposes payment increases for IPPS hospitals and LTCHs
IPPS hospital payments would increase by $2.9 billion, while long-term care hospital rates would grow by $41 billion. Continue Reading
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29 Mar 2024
Skilled nursing facility proposed rule updates payment rates, VBP program
The rule proposed increasing skilled nursing facility payment rates by 4.1 percent. Continue Reading
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28 Mar 2024
CMS proposes 2.8% payment rate boost for inpatient rehabilitation facilities
The agency also proposed adding, removing, and adjusting measures in the inpatient rehabilitation facility quality reporting program. Continue Reading
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28 Mar 2024
Hospital financial performance off to a strong start
New data from Kaufman Hall shows a median monthly operating margin index of nearly 4% in February 2024, building on several months of positive margins. Continue Reading
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25 Mar 2024
Private payers initially deny nearly 15% of medical claims
A new survey from Premier Inc. reveals a high rate of initial claim denials from private payers, including claims pre-approved through prior authorizations. Continue Reading
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14 Mar 2024
Hospital payment cap slashes prices in Ore.
A new study finds a hospital payment cap in the Oregon state employee health insurance plan reduced prices and price variation. Continue Reading
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11 Mar 2024
$460B spending bill averts shutdown, some physician pay cuts
In addition to preventing a government shutdown, the bipartisan spending bill will also reduce the Medicare physician pay cut and delay Medicaid DSH reductions. Continue Reading
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Feature
22 Feb 2024
Breaking Down the Back-End Revenue Cycle, Key Best Practices
When a patient encounter ends, the back end of the revenue cycle gets busy creating claims and managing A/R to optimize revenue collection and integrity. Continue Reading
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12 Feb 2024
From Pilot to Scale, Mount Sinai Leverages Autonomous Medical Coding
Mount Sinai uses autonomous medical coding technology to code about half of pathology cases, with plans to increase volume and scale soon. Continue Reading
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09 Feb 2024
Hospital Groups Rally Against HHS’ Interpretation of DSH Payments Formula
According to HHS, a patient is only entitled to SSI benefits if they receive cash SSI payments during a hospital stay, a warped interpretation that impacts DSH payments, hospital groups said. Continue Reading
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29 Jan 2024
How AI is Becoming a Staple in Medical Coding, Auditing
A new partnership highlights the benefits of AI in medical coding and auditing and its inevitable use in this area of the revenue cycle. Continue Reading
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26 Dec 2023
Understanding the Basics of Bundled Payments in Healthcare
Bundled payment models pay providers a one-time fee for a patient’s episode of care rather than reimbursing for each treatment, test, or procedure. Continue Reading
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13 Dec 2023
House Bill Addresses Price Transparency, Site-Neutral Payment Policies
Hospital groups oppose the bill, asserting that the site-neutral payment policies and reimbursement cuts for hospitals will impact access to care. Continue Reading
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08 Dec 2023
Providers See Fourfold Increase in External Payer Audits
External payer audits quadrupled over the last year, adding pressure to revenue integrity teams already grappling with coding issues. Continue Reading
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27 Nov 2023
How Many Medicare Part D Claims Are Subject to 340B Discounts?
The growth of Medicare Part D claims subject to 340B discounts was driven by increases in claims written by 340B-affiliated clinicians and prescribed by 340B pharmacies. Continue Reading
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21 Nov 2023
Medicare Advantage Denials Jump 56%, Commercial Denials 20%
Claim denials are on the rise as hospitals also see diminishing cash reserves, according to a new AHA report. Continue Reading
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16 Nov 2023
How Did Commercial Payments for COVID-19 Inpatient Stays Vary in 2020?
Commercial payments for COVID-19 inpatient stays were highest at hospitals affiliated with a health system, at $3,562. Continue Reading
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30 Oct 2023
Surprise Billing Proposals Aim to Streamline IDR Process
The surprise billing proposals address the open negotiation process for independent dispute resolutions, batching, and eligibility determinations. Continue Reading
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25 Oct 2023
Patient Access, Registration Errors Lead to Most Claim Denials
Eligibility or mission prior authorization were some of the most common reasons for claim denials, according to a recent survey. Continue Reading
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23 Oct 2023
Reducing Barriers to MIPS, Advanced APMs Could Promote Participation
Rural physicians were deterred by the financial resources, staffing, and health information technology required to participate in an Advanced APM. Continue Reading
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23 Oct 2023
Physician-Owned Hospitals Could Save Medicare Over $1B
A new study finds substantial cost savings when Medicare beneficiaries with the most expensive conditions go to a physician-owned hospital versus a traditional hospital. Continue Reading
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18 Oct 2023
Lower Payment Rates May Help Curb Medicare Spending on Post-Acute Care
Reducing payment rates to skilled nursing facilities, inpatient rehab facilities, and home health providers by 5 percent would’ve saved $2.7 billion in Medicare spending in 2021. Continue Reading
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12 Oct 2023
Gender Pay Disparities in Medicare Reimbursement Impact Neurosurgeons
Female neurosurgeons received almost $25,000 less per year than men after controlling for volume and experience, highlighting gender pay disparities. Continue Reading
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09 Oct 2023
MGMA: Sustainable Financing Needed to Protect Rural Healthcare
Congress needs to avert a looming Medicare payment cut and implement prior authorization reform to improve access to rural healthcare, MGMA says. Continue Reading
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27 Sep 2023
62% of Hospitals Don’t Automate Any Part of Denials Management
A new survey of healthcare finance and revenue cycle leaders shows a lack of denials management automation but plans to move away from manual processes soon. Continue Reading
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26 Sep 2023
Claims Reimbursement Speed, Denial Rate Tied to Location
A recent analysis finds a connection between where a provider operates and how quickly and accurately insurers reimburse claims. Continue Reading
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25 Sep 2023
Firm Selection, Rollout Key Considerations of Revenue Cycle Outsourcing
A new KLAS report provides advice from providers who have outsourced revenue cycle end to end using leading firms like Ensemble Health Partners and R1. Continue Reading
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21 Sep 2023
Claim Denials Pose Expensive Problem for Providers
A survey finds claim denials are revenue cycle management’s greatest challenge, with more than 1 in 5 providers saying they lose $500K in annual revenue because of denials. Continue Reading
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15 Sep 2023
Healthcare Services Cost More at Hospital Outpatient Departments
Colonoscopy screenings cost $611 at a doctor’s office but $1,224 when provided in a hospital outpatient department, a study found. Continue Reading
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14 Sep 2023
Healthcare Orgs Address Price Transparency, 340B Policies in OPPS
AHA also indicated that the payment rate increase proposed in the OPPS is inadequate given the current financial struggles hospitals are facing. Continue Reading
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13 Sep 2023
Provider Groups Oppose Proposed Payment Cuts in Physician Fee Schedule
In addition to opposing the proposed payment cuts, provider groups urged CMS to provide more guidance on E/M coding changes. Continue Reading
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12 Sep 2023
AMA 2024 CPT Code Set Addresses Language Barriers, Immunization Codes
AMA added Spanish descriptors to the 2024 CPT code set and consolidated over 50 codes related to COVID-19 immunizations. Continue Reading
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11 Sep 2023
What the Latest Court Decisions Mean for the Federal IDR Process
Two new court rulings have suspended the federal independent dispute resolution (IDR) process, although they are wins for healthcare providers. Continue Reading
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01 Sep 2023
AHA Opposes Proposed Payment Cuts for Home Health Providers
The payment cuts from the PDGM budget neutrality adjustment and the market basket update will hurt access to home healthcare services, AHA said. Continue Reading
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29 Aug 2023
Exploring Front-End Revenue Cycle, How to Optimize Its Performance
There is a lot that happens before claims management that impacts the revenue cycle. Optimizing front-end steps is vital to a provider’s financial success. Continue Reading
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15 Aug 2023
MGMA: EFT Fees Imposed by Health Plans Are Hurting Providers
Two-thirds of medical groups reported that health plans are charging EFT fees the practices did not agree to. Continue Reading
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14 Aug 2023
CMS Reduces No Surprises Act Fee After Court Vacates Price Hike
The fee for initiating a payment dispute under the No Surprises Act is back to $50 after a federal court recently struck down a 600% increase. Continue Reading
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10 Aug 2023
As Patient Financial Responsibility Grows, Technology Key to Collections
Patient financial responsibility has tightened provider cash flow, but tech has helped one medical group loosen its grip by doubling daily cash collections. Continue Reading
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07 Aug 2023
AHA: Site-Neutral Payment Policies Hurt Hospitals
AHA CEO Rick Pollack took to the WSJ to criticize an opinion piece showcasing higher prices paid for hospital outpatient services. Continue Reading
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27 Jul 2023
How Revenue Cycle Automation Keeps A Physician-Owned Practice Open
Maintaining its independence is vital to the Clinics of North Texas, so the physician-owned practice turned to revenue cycle automation to optimize collections. Continue Reading
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21 Jul 2023
OIG: HRSA Made Improper Payments Through COVID-19 Uninsured Program
In a sample of 300 patients, HRSA made improper payments to providers through the COVID-19 Uninsured Program totaling $294,294. Continue Reading
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Feature
11 Jul 2023
What Payment Integrity Means for Providers, How to Avoid Claim Issues
Payment integrity ensures accurate and timely reimbursement, but it takes robust documentation and coding practices, claims data analysis, and ongoing monitoring. Continue Reading
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07 Jul 2023
Median Per Person Healthcare Spending Exceeds $6K
The Health Care Cost Institute reports median per person healthcare spending has increased by 24% from 2017, but residents of some cities pay far more. Continue Reading
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22 Jun 2023
About a Quarter of Residents in 18 States Have Medical Debt
Medical debt is a major problem for Americans as coverage gaps and inadequate insurance fail to protect patients from excessive patient financial responsibility. Continue Reading
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15 Jun 2023
340B Program Enrollment Led to More Oncology Services at Rural Hospitals
Rural hospitals participating in the 340B program were 8.4 percentage points more likely to have added oncology services than non-participants. Continue Reading
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14 Jun 2023
AHA Decries Inpatient Prospective Payment System Update
The hospital association said the proposed update to the market basket of the Inpatient Prospective Payment System is inadequate, citing market forces and workforce woes. Continue Reading
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07 Jun 2023
OIG: Medicare Overpayments Due to Coding Discrepancies Totaled $22.5M
Practitioners used improper place-of-service codes when billing for physician services, resulting in $22.5 million in overpayments from Medicare. Continue Reading
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06 Jun 2023
Back to the Basics, Other Payment Integrity Strategies Post-PHE
Fraud in healthcare isn’t as black and white as in other industries, so providers need a comprehensive payment integrity strategy after the COVID-19 public health emergency. Continue Reading
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01 Jun 2023
Healthcare Costs for Average Family Exceed $31K
Healthcare costs for people with employer-sponsored coverage increased by 5.6% this year, following a decrease in 2020. Continue Reading
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24 May 2023
Denial Management Calls for More Expertise, Survey Says
Out of 15 revenue cycle tasks, healthcare finance and RCM leaders say denial management requires the most subject matter expertise, followed by prior auths. Continue Reading
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23 May 2023
Over 230 House Reps Join Fight Against Medicaid DSH Cuts
A coalition of House Representatives is calling on Congressional leaders to stop cuts to Medicaid Disproportionate Share Hospital (DSH) payments by Oct. 1st. Continue Reading
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22 May 2023
CMS Announces Start Date for IRF Claims Review Demo
The Review Choice Demonstration (RCD) for Inpatient Rehabilitation Facility (IRF) Services will start in August in Alabama, where CMS will review Medicare claims before or after payment. Continue Reading
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17 May 2023
AHA Makes Hospital Price Transparency Suggestions to Congress
For a committee hearing on healthcare price transparency, AHA touted compliance progress while urging a review of the federal hospital rule. Continue Reading
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15 May 2023
Independent Dispute Resolution Case Load 14X More Than Expected
A status update from the federal government confirms an ongoing backlog of cases in the independent dispute resolution process, which resolves surprise billing disputes. Continue Reading
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10 May 2023
MGMA: Medicare Advantage Growth Exacerbates Prior Authorization Burdens
Most surveyed medical groups provide care to patients with Medicare Advantage plans, meaning they must comply with more prior authorization requirements. Continue Reading
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05 May 2023
340B Drug Pricing Program Eligibility Tied to Lower Biosimilar Use
The rate of biosimilar use was 11.8 percent among hospitals eligible for the 340B drug pricing program and 34.7 percent among non-eligible facilities. Continue Reading
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03 May 2023
Health Disparities in Heart Failure Admissions Cost Over $60M
The annual cost of preventable heart failure admissions among Black Medicare beneficiaries was $125M, with nearly half attributable to health disparities. Continue Reading
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01 May 2023
Provider Groups Band Together to End Cigna’s Modifier 25 Policy
Cigna recently told network providers that it would deny payment for E/M services reported with a modifier 25 if it doesn't receive records documenting a separately identifiable service. Continue Reading
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12 Apr 2023
What Prior Authorization Changes in MA Final Rule Mean for Providers
Healthcare organizations and experts agree that the prior authorization policies in the Medicare Advantage final rule will help reduce administrative burden on providers. Continue Reading
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12 Apr 2023
Major Credit Bureaus Remove Medical Debt Collections Under $500
Equifax, Experian, and TransUnion have announced they wiped medical debt collections under $500 from US credit reports to help consumers during economic uncertainty. Continue Reading
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29 Mar 2023
Provider Org Recommends Changes to MA Prior Authorization Rule
The American Academy of Ophthalmology asked CMS to enforce decision deadlines and clarify denial metric reporting in the Medicare Advantage prior authorization proposed rule. Continue Reading
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28 Mar 2023
Site-Neutral Payments Could Threaten Access to Care, Study Suggests
A study released by the American Hospital Association (AHA) says outpatient departments treat sicker and lower-income patients, indicating site-neutral payments’ threat to access to care. Continue Reading
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27 Mar 2023
Price Transparency Data Reveals Most Expensive Brain MRI Locations
A study of negotiated rates under the new hospital price transparency rule finds that nonprofit and government hospitals charge more for brain MRIs than for-profit hospitals. Continue Reading
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16 Mar 2023
MedPAC Recognizes Impact of Inflation on Docs, Suggests Higher Rates
The advisory group also voted to recommend an add-on payment for physicians serving more low-income beneficiaries. Continue Reading
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15 Mar 2023
ACR Recommends Changes to Prior Authorization Proposed Rule
ACR urged CMS to shorten the prior authorization decision time to 24 hours for urgent requests and include treatments in the gold card program, among other recommendations. Continue Reading
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13 Mar 2023
Practices Complete More Prior Authorizations, See More Care Delays
New data from the American Medical Association shows that the burden of prior authorizations is still very high for physician practices despite provider complaints. Continue Reading
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10 Mar 2023
Biden’s FY24 Budget Aims to Extend Medicare Trust Fund Solvency
The budget proposes raising the Medicare tax rate on high incomes and increasing savings from prescription drug reforms to help extend the Medicare Trust Fund solvency to the 2050s. Continue Reading
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08 Mar 2023
How E/M Payment Policy Changes Impacted Physician Reimbursement
Following E/M payment policy changes, the reimbursement gap between primary care and specialty physicians decreased by just $825, falling from $40,259.80 to $39,434.70. Continue Reading
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07 Mar 2023
As Medicaid Unwinds, Hospitals Seek Relief from DSH Payment Cut
Leading hospital groups ask lawmakers to stop an $8 billion cut to Medicaid Disproportionate Share Hospital (DSH) payments later this year. Continue Reading
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06 Mar 2023
Providers are Increasingly Billing Outpatient Visits at Higher Levels
The share of outpatient visits billed at the two highest complexity levels increased from 24 percent in 2004 to 43 percent in 2021. Continue Reading
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15 Feb 2023
Lessons from the NSA’s Independent Dispute Resolution (IDR) Process
A healthcare lawyer shares some surprising lessons learned from her experience with the No Surprises Act’s independent dispute resolution (IDR) process for out-of-network claims. Continue Reading
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07 Feb 2023
TX Physicians Win No Surprises Act Rule Court Case
A district court has ruled in favor of the Texas Medical Association, which has challenged HHS’ No Surprises Act rule describing the independent dispute resolution process. Continue Reading
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06 Feb 2023
How Healthcare Organizations Can Help Improve Social Risk Interventions
Healthcare organizations must foster positive relationships with community-based organizations and may have to leverage multiple payment approaches to effectively impact social risk interventions. Continue Reading
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06 Feb 2023
From AI to Regulation, Making Progress with the Prior Authorization Process
Thanks to technology the prior authorization process is less manual. However, providers are still looking for real transformation through regulation to resolve ongoing issues. Continue Reading
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01 Feb 2023
Two-Thirds of People Evade Coverage After Medicaid Disenrollment
Pandemic-era legislation allowed Medicaid programs to keep people continuously enrolled, but new data spells trouble for people and provider revenue when that expires. Continue Reading
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12 Jan 2023
Should Population-Based Payments Account for Social Risk Factors?
A new study shows that adding social risk factors to risk adjustment models for population-based payments may entrench, not improve, health disparities. Continue Reading
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11 Jan 2023
Judge Wants HHS to Remedy 340B Underpayments to Hospitals
In a disappointing decision for hospitals, a federal court has decided to allow HHS to propose a remedy for an estimated $10B in 340B underpayments. Continue Reading
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06 Jan 2023
AHA Urges MedPAC to Consider Higher Medicare Payment Updates for 2024
According to AHA, MedPAC’s final recommendations should include higher Medicare payment updates that account for inflation and the reimbursement cuts included in the Physician Fee Schedule. Continue Reading
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03 Jan 2023
Federal IDR Process Faces More Disputes Than Expected, Backlog Growing
The federal independent dispute resolution (IDR) process is facing a backlog of payment disputes as it has trouble determining dispute eligibility under the No Surprises Act. Continue Reading
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27 Dec 2022
Medicare Part B Spending on Laboratory Tests Totaled $9.3B in 2021
Medicare Part B spending on laboratory tests grew by $1.3 billion, rising from $8 billion in 2020 to $9.3 billion in 2021, OIG found. Continue Reading
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22 Dec 2022
OIG Identifies Provider Noncompliance when Claiming Medicare Bad Debts
CMS inappropriately reimbursed 22 providers for Medicare bad debts because the Medicare administrative contractors did not prioritize reviewing bad debts during cost report audits. Continue Reading
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14 Dec 2022
Study: Safety-Net Hospitals Miss Out on Some Medicaid DSH Payments
Some Medicaid DSH payments went to hospitals that did not serve a disproportionate share of Medicaid patients or provided high levels of uncompensated care. Continue Reading
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08 Dec 2022
Providers, Payers In Ongoing "Tug-of-War” Over ED Coding, Study Says
ED coding may be contributing to a significant increase in high-intensity billing for emergency care services as a new study finds only about half of that increase was expected. Continue Reading
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07 Dec 2022
Payment Rate Policies Contributed to Lower Medicare Spending Growth
Between 2012 and 2015, 44 percent of the decline in Medicare spending growth was attributed to lower increases in payment rates, sequestration policies, and changes in beneficiary characteristics. Continue Reading
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02 Dec 2022
AHA, AMA Urge Congress to Prevent Medicare PAYGO Sequester
Coupled with the 4.5 percent reduction in the Physician Fee Schedule, the 4 percent Medicare PAYGO sequester will result in an 8.5 percent payment decrease for physicians next year if Congress does not act. Continue Reading