Category: Blog

Prior Authorization Reform: Progress and Positive Steps

Prior Authorization Reform: AMA’s Impact on Doctors, Patients

 Prior Authorization Reform, a lengthy and often frustrating process for payers to control costs, remains a major challenge for doctors. A recent AMA survey of 1,001 physicians found that 89% of physicians believe prior licensure hurts clinical practice. A surprising 33% said the worst things, such as death or hospitalization, were rights-related.  The AMA recognized […]
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2025 CMS Proposed Rules

2025 CMS Proposed Rules for Hospice, Palliative Care, and More

It’s April, and that means it’s time for proposed rules for fiscal year 2025  to emerge. But the Centers for Medicare and Medicaid Services (CMS) prevailed this year, releasing proposed rules for inpatient rehabilitation, psychiatric patients, hospitals, and skilled nursing facilities (SNFs) in late March. I thought a suggestion was worth mentioning. Additional Benefits for […]
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CMS Improves Outcomes & Reduces Costs with Specialty Care

Specialty care improves outcomes and reduces costs for CMS

Streamlining Specialty Care: CMS’s Innovation Center prioritizes strategies that improve personalized healthcare information, implement financial services, and support segment-based classifications. A value-based approach to care must address underlying issues and individualized care to reduce patient outcomes. CMS’s innovation strategy describes ongoing efforts to integrate personalized care into the healthcare system. Previous studies have shown that […]
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Interoperability-and-Prior-Authorization

CMS released the CMS Interoperability and Prior Authorization final rule

CMS Interoperability and Prior Authorization Final Rule: On January 17, 2024, the Centers for Medicare and Medicaid Services (CMS) published the CMS Interoperability and Prior Authorization final rule (CMS-0057-F). The final rule aims to reduce the burden on patients, providers, and payers by consolidating the authorization process and moving the industry electronically. Affected payers must […]
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Auditing facility services using a three-pronged approach

Auditing Facility Services: Changes to evaluation and management (E/M) services in 2021 and 2023 have excited and confused auditors. I am glad that the seemingly trivial criteria required for the level of service (history, testing) are an advantage to confusion when implementing new medical decisions (MDM)  in a balanced environment. In early 2021, AAPC Services […]
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Prior Authorization Transformation

How Prior Authorization Transformation Benefits Patients, Providers and  Payers

Prior authorization transformation of consent is a source of worry and concern for everyone involved: patients, members, providers, and payers. What was needed was a structure to coordinate all stakeholders and organize the program. In January 2024, the Centers for Medicare and Medicaid Services (CMS) finalized requirements to expedite the authorization process; this requirement will […]
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When to Use Modifiers 52, 73, 74

Demystifying Facility Coding

Modifiers 52: Professional fee-for-service guidelines for modifiers do not apply in the clinical setting. Reduced, Failed, Aborted, Aborted… which one? What are the requirements for using modifiers 52, 73 and 74? These questions are common in the coding center world, and  the answers  never seem to be clear. Confusingly mix up the medical code instructions […]
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HIPAA compliance importance

HIPAA compliance importance: Key Requirements, Consequences, and Tips

What is HIPAA? HIPAA compliance importance: It is important to note that the Health Insurance Portability and Accountability Act (HIPAA) Security Rule of 1996 established standards for protecting individuals’ electronic personal health information (PHI). This includes any identifiable health information, such as medical records and histories, medical bills, and lab results, among others. A covered […]
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Survey: High Initial Claim Denials Impact Healthcare Providers

The Rising Denial Rates in Healthcare Claims Processing Initial Claim Denials: In a new survey conducted by healthcare Company an increased percentage of initial claims are denied by private payers, including pre-approvals for medical claims. Hospitals, health systems, and post-acute care providers may have a difficult time getting paid for medical services. The survey respondents […]
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5 Ways to Reduce Claims Denial in Your Revenue Cycle

Reduce Claims Denial in Your Revenue Cycle

Claims Denial: Healthcare Leaders report an increase in payer denials, putting increasing pressure on the system’s finances. Going back and forth with denied payers is a long and expensive process, and low reimbursement rates don’t help either. In a new survey conducted by the Healthcare Financial Management Association, CFOs noted a significant increase in denials, […]
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