Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Processing

Change Healthcare, Health Fidelity Apply AI to Risk Adjustment

January 14, 2019 - 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 machine learning to increase the accuracy of claims and help health plans meet their compliance obligations. By transforming the risk adjustment...

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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...

Poor Data Quality in CA Medicaid Drives $4B in Improper Payments

by Thomas Beaton

California's Medicaid program, Medi-Cal, made over $4 billion in improper payments to cover benefits for ineligible beneficiaries because of poor data quality and insufficient oversight, according to a new report from state...

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...

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...

IT Investment to Help VA Speed Claims Administration, Payment

by Thomas Beaton

The Department of Veterans Affairs (VA) has announced new goals for claims administration and a significant investment in health IT tools that will help coordinate payment for community providers. The VA has set the goal of increasing the...

How Payers, Providers Could Streamline Medical Claims Management

by Vera Gruessner

Successful medical claims management and processing is not always easy to garner for health insurance companies due to a lack of training among insurance agents, missing or inaccurate documentation, and the general time-consuming...

Key Ways Payers Could Improve Medical Claims Management

by Vera Gruessner

Medical claims management is a key aspect of the payer-provider relationship. However, medical claims management tends to include multiple challenges for both payers and providers. Some of the problems stem from a lack of training in...


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