Claims Management

No Surprises Act Prevented 10M Surprise Medical Bills, But IDR Use Grows

January 30, 2024 - The No Surprises Act (NSA) helped prevent 10.1 million surprise medical bills in the first nine months of 2023, according to a survey from AHIP and the Blue Cross Blue Shield Association (BCBSA). The No Surprises Act took effect on January 1, 2022, for those enrolled in commercial health insurance or group health plans. The law states that when...


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Lawsuit Alleges Humana Used AI to Deny Medically Necessary Claims

by Victoria Bailey

Humana is facing a class action lawsuit alleging that the payer used an artificial intelligence (AI) tool to deny Medicare Advantage beneficiaries’ claims for medically necessary care. In a...

What Technologies Support Payers With Claims Management Processes?

by Victoria Bailey

Claims management is an integral part of the healthcare process as it determines how much providers receive in reimbursement, what costs health plans will cover, and what patients ultimately owe for their care. After providing care,...

UnitedHealthcare Pays $91.2M After Underpaying Envision for Medical Care

by Victoria Bailey

After underpaying the medical group for essential care, UnitedHealthcare has been ordered to pay $91.2 million to Envision Healthcare (Envision). An independent three-member panel of the American...

ACA Marketplace Plans Denied Nearly 17% of In-Network Claims in 2021

by Victoria Bailey

Non-group qualified health plans (QHPs) on the Affordable Care Act (ACA) marketplace denied, on average, almost 17 percent of in-network claims in 2021, according to an issue brief from the Kaiser...

Employers Juggle High Healthcare Spending, Hiring Challenges in 2022

by Kelsey Waddill

Employers are looking for answers as they face an ever-steeper healthcare spending trajectory and hiring challenges in the post-pandemic environment, according to a survey from the National Alliance of...

No Surprises Act May Have Blocked 2M Surprise Billing Claims

by Kelsey Waddill

Since the No Surprises Act went into effect, the law has prevented more than two million surprise billing claims in its first two months of enactment, according to a survey from AHIP and the Blue Cross...

Org Streamlines Billing, Authorizations in Public Payer Coverage

by Kelsey Waddill

CalOptima—a county-organized health system that offers care through public payer coverage, including Medicaid, Medicare Advantage, and Medicare-Medicaid plans—is launching a five-year...