Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management

Da Vinci Project Connects Payers, Providers, FHIR for Value-Based Care

September 10, 2018 - Payer and provider members of the Da Vinci Project are undertaking a series of pilot projects exploring how to best leverage FHIR for data exchange to enhance value-based care. “Da Vinci is a collective initiative of concerned, diverse market leaders that include payers, providers, HL7 and EHR vendors that understand how critical it is to put forward and employ standards that...


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CAQH CORE Urges Industry Collaboration on Prior Authorizations

by Thomas Beaton

CAQH CORE is urging healthcare payers, providers, and other stakeholders to promote industry-wide collaboration on how to improve prior authorizations. Leading provider and payer organizations, including AHIP, AHA, the BlueCross...

All-Payers Claims Databases May Increase Healthcare Price Transparency

by Thomas Beaton

Leveraging the data of all-payers claims databases (APCDs) could improve healthcare price transparency for consumers, according to testimony presented at a House Energy and Commerce Committee hearing. Jamie S. King, a professor at the USC...

Automated Claims Administration Could Bring Billions in Savings

by Thomas Beaton

Automated claims administration could bring around $11 billion in savings to health plans and providers if the technology is implemented more broadly, according to the latest CAQH Index. Payers should encourage providers to adopt...

Quality Analytics, Risk Adjustment Tools Prep Payers for Success

by Thomas Beaton

Quality analytics and risk adjustment technologies are effective solutions for payers when these tools can structure claims and clinical information into actionable models, identify multiple risk indicators, and foster provider...

HHS Made Nearly $90B in Improper Payments to Medicaid, Medicare

by Thomas Beaton

HHS made approximately $90 billion in improper payments to Medicaid and Medicare programs during 2017 and may require updated payment evaluation procedures to address improper payments, a new Government Accountability Office (GAO) report...

NYCHH Seeks $11.5M from UnitedHealthcare for Denied Claims

by Thomas Beaton

A New-York based health system has initiated arbitration with UnitedHealthcare in order to collect $11.5 million in denied reimbursement from claims. NYC Health + Hospitals, a public healthcare network that serves New York City’s...

How Can Payers Get Providers to Use Electronic Payment Systems?

by Thomas Beaton

Healthcare, an industry that lags behind others in technology adoption, is slow to embrace innovative solutions that address business challenges. For payers that want to implement electronic payment systems to improve claims reimbursement,...

GAO: Medicare DME Prior Authorization Programs are Effective

by Thomas Beaton

CMS’s prior authorization programs for durable medical equipment (DME) and mobility devices created between $1.1 and $1.9 billion in Medicare savings from 2012 to 2017 by controlling unnecessary spending, according to a new...

Medicare Advantage Data Transparency Can Enhance Insights

by Thomas Beaton

Expanding Medicare Advantage data transparency may allow researchers to gain more comprehensive insights into cost and quality within the popular MA program. Healthcare experts and academic organizations currently have limited Medicare...

GAO Finds Several Medicare Beneficiary Data Vulnerabilities

by Thomas Beaton

CMS may have significant Medicare beneficiary data vulnerabilities because of security standards gaps within organizations that review and audit Medicare performance, a new GAO report found. GAO found security risks based on discrepancies...

OIG: Medicare Could Save $367M by Auditing Improper Payments

by Thomas Beaton

CMS auditing systems failed to recognize that 61 percent of Medicare payments for outpatient physical therapy claims in 2013 were improperly filed, which cost the Medicare program nearly $367 million, says a new report by the OIG. Only...

Urgent Care Center Utilization Skyrocketed by 1725% in Last Decade

by Thomas Beaton

Healthcare payers saw urgent care center utilization grow by 1725 percent from 2007 to 2016, indicating that urgent care may the one of the fastest-growing choices for receiving healthcare. A white paper from FAIR Health found that...

Prior Authorization Issues Contribute to 92% of Care Delays

by Thomas Beaton

Prior authorization issues are associated with 92 percent of care delays and may contribute to patient safety concerns as well as administrative inefficiencies, according to a new survey from AMA. Payers should work to change their prior...

CMS: Payers Must Make Claims Data Available to Beneficiaries

by Thomas Beaton

CMS Administrator Seema Verma recently called on healthcare payers to make claims data available to their beneficiaries. The agency also announced a new initiative called MyHealthEData to give patients control of their healthcare...

Medicare Advantage Evaluation Requires Transparent Claims Data

by Thomas Beaton

The growth of the Medicare Advantage (MA)  market requires the release of more claims data to evaluate the commercial and government impact of the program, according to a recent JAMA commentary from the Health Care Cost Institute,...

96% of Payers Are Committed to Electronic Prior Authorization

by Thomas Beaton

The vast majority of payers are committed to implementing electronic prior authorization solutions as a way to address administrative problems with prior authorization procedures, according to research published through the ePA National...

CA to Investigate Aetna after Insurance Claim Review Admission

by Thomas Beaton

The California Insurance Commission has opened an investigation into Aetna’s medical practices after a former medical director for the company testified in court that he did not review patient records before approving or denying...

How All-Payer Claims Databases Can Identify Wasteful Spending

by Thomas Beaton

An all-payer claims database (APCD) can hold data on millions of patients and the services they receive, giving payers, providers, and related stakeholders the ability to identify wasteful spending and develop strategies to cut costs and...

2018 Best in KLAS Taps Vendors for Claims Admin, Price Transparency

by Thomas Beaton

The 2018 Best in KLAS report ranked the best vendor solutions for payer claims administration, care management, price transparency, and payer analytics based on five industry performance criteria.    KLAS ranked vendor solutions...

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