Claims Management News

Lawsuit Alleges Humana Used AI to Deny Medically Necessary Claims

December 14, 2023 - 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...


Articles

Trends in Price Ratios Between Commercial, Medicare Advantage Plans

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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

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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

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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...

Medicare Coverage Policies Can Result in Millions of Denied Claims

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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

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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...

KLAS Identifies Top Vendor for Core Administration Platforms

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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...

The Changing Landscape of Healthcare B2B Payment Transactions

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Healthcare B2B payment transactions have been high in 2021, potentially signaling the importance of electronic payment transfers as the nation emerges from the coronavirus pandemic, according to a...

Electronic Payment Adoption Key to Healthcare Industry Savings

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The majority of the healthcare industry has taken to digitizing payments over the past few years. Still, ample opportunities remain for providers and plans to significantly reduce costs and realize...

How Payers Can Improve Attachment Processes in Claims Management

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Claims management is a multi-step process that provides ample opportunity for errors and delays, but if payers modify their approach to certain steps in the process it could have a positive impact...

3 Types of Funding for Employer-Sponsored Health Plan Claims

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Employers have three primary options to choose from when they are deciding how to fund their employer-sponsored health plan claims: the self-insured, level-funded, or fully-insured health plan...

How Payers Can Make Medical Billing More Streamlined, Transparent

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Medical billing is notoriously complicated and taxing for members and providers alike. But payers have the ability—and, some might argue, the responsibility—to clarify and simplify the...

Payers Denied 17% of 2019 In-Network Claims on ACA Marketplace

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Certain Affordable Care Act marketplace policies need to be tweaked in order to support greater consistency across transparency data reporting processes, a recent Kaiser Family Foundation...