Lawsuit Alleges Humana Used AI to Deny Medically Necessary Claims
- 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 complaint filed in the US District Court for the Western District of Kentucky, the plaintiffs said Humana continues to use naviHealth’s nH Predict...
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How Human and Artificial Intelligence Can Streamline Claims Reviews
Amid the shifting landscape of medical claims, the rise of high-cost and complex claims has become a significant challenge for payers. Recent data from the Peterson Center on Healthcare and Kaiser...Sponsored Article
Blending Human Expertise & Technology to Improve Claims Negotiations
Out-of-network claims remain a challenge for a healthcare system looking to improve utilization and spending of services. For health plans, negotiating fair prices for out-of-network services is...Sponsored Article
Improving Payment Integrity with a Building Blocks Methodology
Healthcare costs are increasing, and health insurers can expect — by some estimates — to spend 7 percent more in 2024. In this environment, payment integrity teams have a strategic...Trends in Price Ratios Between Commercial, Medicare Advantage Plans
Insurers often negotiate hospital prices for their commercial health plans that are up to five times the Medicare Advantage price, a study published in Health Affairs found. It was already a...KLAS: Payers Want Efficient Claims and Administration Platforms
Payers prefer to utilize claims and administration platforms from vendors that are efficient, manage multiple business lines, and can meet their complex needs, according to a KLAS report. The Payer...No Surprises Act May Have Blocked 2M Surprise Billing Claims
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...Sponsored Article
5 Reasons Why Payers Should Bolster Payment Integrity
Payers can elevate their payment integrity strategy to do much more than fraud, waste, and abuse prevention. A comprehensive payment integrity strategy is key to lowering costs and achieving higher...Medicare Coverage Policies Can Result in Millions of Denied Claims
The share of denied claims in Medicare is largely attributable to laboratories, according to a study published in Health Affairs. Researchers worked with Aetna and Medicare data to assess the number...ACHP Asks CMS To Set At-Home COVID-19 Testing Coverage Standards
In a letter to CMS, the Alliance of Community Health Plans (ACHP) has requested that the federal government establish certain requirements for at-home COVID-19 testing coverage. “We support the...Sponsored Article
As High-Dollar Claims Come In, Focus on Payment Integrity Is Key
Overall healthcare spending is slated to increase exponentially over the course of the next few years, and private payers are expected to foot a large portion of the bill. The Office of the Actuary at...Sponsored Article
How Pre-Payment Review Elevates Payer Payment Integrity
Payer payment integrity strategies are generally built around post-payment reviews to ensure appropriate reimbursement was sent to providers for medically necessary services. However, truly...KLAS Identifies Top Vendor for Core Administration Platforms
Core administration platforms are essential to a payer’s functions and KLAS has identified one platform that pulls ahead of most of its competitors on most metrics, according to a KLAS report...Sponsored Article