Claims Management News

Cigna Embroiled in Lawsuit Over Wellness Program Risk Adjustment

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A lawsuit was filed against Cigna on August 4, 2020 for $1.4 billion in false and fraudulent risk adjustment claims between 2012 and 2017, according to a court filing obtained by Axios. The...

Lawsuit Against UHC Stresses Overpayment Recovery in Employer Plans

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A class-action lawsuit against UnitedHealthcare is revisiting how overpayment recovery and cross-plan offsetting affect member costs in employer plans. The lawsuit—Scott v. UnitedHealth...

Most Payers Cover Member Costs for COVID-19 Testing, Treatment

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Health payers recognize the importance of COVID-19 testing and treatment to keep their members healthy and fight the pandemic. That is why a majority are covering the costs of testing and treatment...

Public, Private Payers Offer Upfront Reimbursement Amid COVID-19

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Public and private payers are looking to support provider organizations during the unprecedented COVID-19 crisis by advancing claims reimbursement and relaxing certain billing requirements, like prior...

Payer Claims, Economics, Operations Will Suffer Due to COVID-19

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Health payers will be exposed to claims-based, economic, and operational challenges due to the COVID-19 pandemic, according to an AM Best report sent to HealthPayerIntelligence by email. The report...

KLAS Ranks Top Healthcare Payer, IT Consulting Services

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As healthcare payers work to modernize their healthcare technologies, or even adopt new ones, it will be essential for them to be knowledgeable about the consulting services that may aid those health...

Prevalence of Balance Bills Varies by State, Medical Specialty

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Certain states and medical specialties account for larger shares of out-of-network claims and balance bills for inpatient hospital admissions, according to a study conducted by the Health Care Cost...

Payer-Provider Providence St. Joseph Buys Blockchain RCM Company

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Providence St. Joseph Health (PSJH), an integrated payer-provider system, has announced the acquisition of Lumedic, a blockchain company serving the revenue cycle management market. The purchase will...

2019 Best in KLAS Taps Payer Price Transparency, Claims Solutions

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Change Healthcare, Health Solutions Plus (HSP), and Casenet were among the top-ranked solutions in the 2019 Best in KLAS report for price transparency, payer claims and administration, and payer...

Change Healthcare, Health Fidelity Apply AI to Risk Adjustment

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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...

Spending, Prescription Histories Identify Future High Cost Members

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An individual’s healthcare spending and prescription drug histories are among the most accurate predictors of future high costs, according to a new Society of Actuaries (SOA) report. SOA used...

Da Vinci Project Connects Payers, Providers, FHIR for Value-Based Care

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Payer and provider members of the Da Vinci Project are undertaking a series of pilot projects exploring how to best leverage FHIR for data exchange to enhance value-based care. “Da Vinci is a...

CAQH CORE Urges Industry Collaboration on Prior Authorizations

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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,...

All-Payers Claims Databases May Increase Healthcare Price Transparency

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Leveraging the data of all-payers claims databases (APCDs) could improve healthcare price transparency for consumers, according to testimony presented at a House Energy and Commerce Committee...

Automated Claims Administration Could Bring Billions in Savings

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Automated claims administration could bring around $11 billion in savings to health plans and providers if the technology is implemented more broadly, according to the latest CAQH Index. Payers should...

Preventing Provider Fraud through Health IT, Data Analytics

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Healthcare fraud is an industry-wide problem can impact a payer’s ability to protect their revenue streams and maintain financial integrity. Fraud costs the nation’s healthcare payers...

NYCHH Seeks $11.5M from UnitedHealthcare for Denied Claims

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A New-York based health system has initiated arbitration with UnitedHealthcare in order to collect $11.5 million in denied reimbursement from claims. NYC Health + Hospitals, a public healthcare...

How Can Payers Get Providers to Use Electronic Payment Systems?

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Healthcare, an industry that lags behind others in technology adoption, is slow to embrace innovative solutions that address business challenges. For payers that want to implement electronic payment...

GAO: Medicare DME Prior Authorization Programs are Effective

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CMS’s prior authorization programs for durable medical equipment (DME) and mobility devices created between $1.1 and $1.9 billion in Medicare savings from 2012 to 2017 by controlling unnecessary...

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

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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,...