Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management

HCTTF Offers Clinical Episode Grouper Resources for Bundled Payments

January 16, 2019 - The Health Care Transformation Task Force (HCTTF) has released a new set of resources to support payers as they develop innovative bundled payment programs. In a white paper titled Episode Groupers: Key Considerations for Implementing Clinical Episode Models, HCTTF offers guidance on how to develop the analytics logic to group services into standardized bundles for...


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Change Healthcare, Health Fidelity Apply AI to Risk Adjustment

by Jennifer Bresnick

Change Healthcare and Health Fidelity have announced a collaboration to offer AI-driven risk adjustment coding solutions for Medicare Advantage, ACA commercial, and Medicaid payers. The tool leverages natural language processing (NLP) and...

HHS Signals End to Health Plan Identifiers in New Proposed Rule

by Kyle Murphy, PhD

Years of pushback from industry stakeholders has motivated an HHS proposal to eliminate a federal requirement for identifying health plans in HIPAA transactions. As everyone prepares to break for the holidays, the federal agency formally...

Spending, Prescription Histories Identify Future High Cost Members

by Thomas Beaton

An individual’s healthcare spending and prescription drug histories are among the most accurate predictors of future high costs, according to a new Society of Actuaries (SOA) report. SOA used claims data collected by the Health Care...

NYCHH Triples Denials Recovery from UnitedHealthcare to $40.1M

by Thomas Beaton

NYC Health + Hospitals (NYCHH) has more than tripled the amount the health system is seeking in claims recovery from UnitedHealthcare, from $11.1 million to $40.1 million after a comprehensive case-by-case review of high-profile...

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

by Thomas Beaton

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,...

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...

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