Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management News

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

March 29, 2018 - 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 116 out of 300 sample claims were submitted correctly, the report states. The remaining 184 claims were improperly filed for $12,741. OIG used the sample findings...


Articles

Prior Authorization Issues Contribute to 92% of Care Delays

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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 authorization...

Medicare Advantage Evaluation Requires Transparent Claims Data

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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, ProPublica,...

96% of Payers Are Committed to Electronic Prior Authorization

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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 Adoption...

NCQA Seeks Stakeholder Comments on Updated HEDIS Measures

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NCQA is seeking health plan, provider, and related stakeholder public comments to weigh in on updated HEDIS measures and the implementation of new measures related to chronic disease management. NCQA wants to implement measures related to patient...

How All-Payer Claims Databases Can Identify Wasteful Spending

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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 reduce...

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

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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 based...

VA Awards Accenture $62M Benefits IT Infrastructure Contract

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Accenture received a one-year, $62 million contract by the VA’s Veterans Benefit Administration (VBA) division to improve the VBA’s technology infrastructure for delivering member benefits. Accenture Federal Services (AFS) will upgrade...

Payers, Providers Pledge to Improve Prior Authorizations

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AHIP, BCBSA, AHA, and other leading payer and provider organizations announced an industry pledge to improve the efficiency of prior authorizations while reducing administrative burden. Leaders of organizations participating in the pledge claim...

All-Payer Claims Databases Offer Insights into Healthcare Spending

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All-payer claims databases (APCDs) allow payers, providers, and regulators to analyze claims from millions of beneficiaries to learn where spending is directed and whether or not spending on certain healthcare services is avoidable. State-level...

How Payers Can Streamline Prior Authorization for Prescriptions

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Prior authorization may allow payers to limit unnecessary spending on high-cost prescription drugs, but leading provider experts suggest that payers could do more to boost the efficiency of prior authorization procedures for clinically valid...

Medical Device Data, UDIs on Claims Impact Costs, Patient Safety

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Adding medical device data and unique device identifiers (UDIs) to insurance claims could have a significant positive impact on healthcare spending and patient safety, according to reports from Pew Charitable Trusts, Brigham and Women’s...

Claims Analytics Help Medicare Identify, Prevent Provider Fraud

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Close to a quarter of new Medicare fraud investigations started with the use of a claims analytics platform that has helped to save approximately $6.7 million in incorrect billings, a new GAO report found.   After reviewing fraud prevention...

Pre-Authorizations, Rx Limits Cut Opioid Abuse by 30% Nationwide

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Anthem BlueCross BlueShield (BCBS) organizations across the country collectively pledged to lower opioid abuse by 30 percent, and the company as a whole reached that goal two years ahead of schedule according to a press release. Declared a national...

Small Employer Health Plan Quality on Par with Larger Groups

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Small employer health plans can deliver similar levels of quality with many of the same cost controls as larger employers, according to new research from United Benefits Advisors (UBA). A “less is more” approach can provide significant...

Stop-Loss Insurance a Growing Market Opportunity for Healthcare

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Even though payers may experience higher total revenues on commercial self-insurance, stop-loss and third-party protected insurance revenues have been growing at a higher rate with stronger market stability according to market research from AM...

Explaining Out-of-Pocket Costs May Ease Cancer Care Stress

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Patients who are not prepared for the magnitude of their out-of-pocket costs for cancer care are more likely to be distressed and less likely to pay their bills than other individuals, according to a research letter published in JAMA Oncology....

Can Healthcare Price Transparency Tools Cut Costs for Payers?

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As out-of-pocket costs for patients continue to rise alongside payer spending on services, many health insurance companies are turning to online price transparency tools to help beneficiaries decide how to purchase low cost, high quality care....

CMS Approves State Capitated Medicaid Program in Florida

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Florida received CMS approval to operate a state capitated Medicaid program and a low-income pool (LIP) to improve care for uninsured individuals, the federal agency announced. The state submitted a request to extend Florida’s Managed Medicaid...

Employer Cost Management Strategies Combat High Insurance Costs

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Employers expect healthcare spending to increase by 5.5 percent in 2018, up from a 4.6 percent increase in 2017, according to a Willis Towers Watson survey. The continued rise in costs has turned health cost management as a top employer concern,...

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