Prior Authorization AI and the Future
Prior Authorization AI and the Future - The process of prior authorization can be time-consuming and complicated for healthcare providers.
Understand Claim Denials Affecting Reimbursement in Healthcare
To understand claim denials affecting reimbursement requires data. In healthcare, claim denials occur when an insurer or payer refuses to reimburse a healthcare provider for a particular medical service or treatment. Claim denials can occur for a variety of reasons, such as inaccurate or incomplete billing information, lack of medical necessity, or failure to follow the proper billing procedures.
Independent Peer Review Streamlines RCM
Independent peer review plays a crucial role in revenue cycle management for the healthcare industry. Revenue cycle management (RCM) refers to the process of tracking patient care from registration to final payment, including all the administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue.
Prior Authorization Process Improvements
Prior authorization is a utilization management process used by some health insurance companies for determining if the patient’s health policy covers a prescribed services, like procedures, tests, or medications, before services are rendered. While intended to control healthcare costs, prior authorizations can be a significant burden on healthcare providers and can delay patient care.
No Surprise Act Includes More Than Price Transparency
No Surprises Act (NSA) protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.
Top At-Risk Conditions and Utilization Spikes
Top At-Risk Conditions and utilization spikes that healthcare leaders and stakeholders across the industry must prepare to proactively address in the upcoming year highlight the recently released, 2023 State of Health – In The Aftermath Report. The report also presents predictive findings and explores the top contributing factors of many utilization increases.
CMS Star Ratings Major Setback for 2 Insurers
The federal government hit CVS Health and Centene with lower quality scores for the health-insurance plans they sell to seniors. Star Rating scores are a big deal for health insurers, because plans that score 4 stars or higher receive bonus payments from the federal government that they can use to edge out competition by funding new health-plan benefits to attract more customers.
Utilization Review vs Utilization Management
Utilization Review and Utilization Management are very critical in the healthcare continuum. While the two terms often feel interchangeable, in reality their processes and meanings actually are very different. Their differences make all the difference for improving care.
ASAM Criteria: Benefits of Speaking the Same Language of Care
ASAM Criteria set guidelines for length of stay and level of care for behavioral health. BHM Healthcare Solutions offers objective peer reviews based on medical necessity criteria, like ASAM's, for complex, medical, and behavioral health cases.
AHA Tackles Social Determinants of Health
The American Hospital Association has opened applications for its second annual AHA Innovation Challenge.