Category: Blog

Medicare Advantage organization determinations

CMS Clarifies Organization Determinations: Key Updates for Medicare Advantage

The Centers for Medicare & Medicaid Services (CMS) has introduced significant updates to clarify the definition and processes related to Medicare Advantage organization determinations, particularly in inpatient settings. The proposed rule reaffirms that decisions made during concurrent reviews, such as reclassifying an inpatient admission to outpatient or denying inpatient coverage, qualify as organization determinations under […]
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Medicare Advantage contract

Avoiding Medicare Advantage Contract Pitfalls: A Guide for Physician Practices

It’s a story many physician practice owners know all too well. A hardworking doctor secures a promising Medicare Advantage contracts with a major payer, expecting substantial revenue—100% of Medicare fee-for-service rates. The new contract seems like a win: more resources for staff, improved facilities, and better patient care. Table of Contents Common Contractual Pitfalls Best […]
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Improve revenue cycle management

Effective 5 Ways to Improve Revenue Cycle Management

The healthcare industry operates under a unique framework. Unlike traditional businesses where customers pay directly for a product or service, healthcare providers navigate a complex system involving multiple players, including payers, claims management, and reimbursements. To Improve Revenue Cycle Management, healthcare providers must understand this intricate system and implement efficient strategies to optimize their revenue […]
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2025 CPT Code Updates

2025 CPT Code Updates: Key Changes in Billing and Coding Practices

Each year, updates to CPT® codes are introduced to reflect advancements in medical procedures and technologies, impacting billing and coding across multiple specialties. Effective January 1, these annual updates encompass new, revised, and deleted codes, along with updated coding guidelines. For 2025 CPT Code Updates, there are 270 new codes, 112 revised codes, and 49 […]
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Insurance Claim Denials

Navigating Insurance Claim Denials: A Step-by-Step Guide

Imagine receiving an Insurance Claim Denials notice that states services are not covered or require prior authorization. Table of Contents Requires Prior Authorization Coverage Terminated or Member Not Eligible on the Date of Service Services Performed are Non-Covered Maximum Benefit for This Service Has Been Met Steps for Obtaining Authorization The Importance of Verification and […]
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ICD-10 medical billing outsourcing

ICD-10 Medical Billing Outsourcing: A Strategic Solution for Healthcare Providers

The healthcare industry is in a perpetual state of change. A significant milestone occurred when the United States mandated the use of ICD-10 billing codes. This shift transformed billing procedures for medical providers, from solo physician practices to large hospitals. As a result, ICD10 medical billing outsourcing has become a critical solution for managing the […]
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Hospital Price Transparency Compliance

Hospital Price Transparency Compliance Drops Significantly

Compliance with federal price transparency rules among hospitals dropped significantly, from 34.5% in February to 21.1% in November 2024, per a report by Patient Rights Advocate (PRA). This decline highlights the challenges in achieving full Hospital Price Transparency Compliance. The drop is attributed to weak federal enforcement, which has allowed hospitals to obscure pricing information […]
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Historical Medical code set

Mastering Historical Medical Code Sets for Audits, Appeals, and Research

Remaining up-to-date is essential in the healthcare industry, but relying solely on current codes isn’t always the best approach. When auditing, handling appeals, or researching code usage for past encounters, a solid grasp of the descriptors and guidelines applicable during the date of service (DOS) can profoundly impact outcomes. Here’s a concise guide on effectively […]
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healthcare billing

How AI Revolutionizes Healthcare Billing: Tackling Payment Delays and Denials

During pediatric cardiology internship, witnessed this firsthand. A claim filed nearly a year earlier remained unpaid. The initial denial was due to a missing prior authorization number, a detail buried within the EMR. Unfortunately, the outsourced healthcare billing team took months to decipher this information, causing significant delays in reimbursement. This year-long ordeal highlights the […]
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Charge Capture in Healthcare

Charge Capture: A Critical Step in Revenue Cycle Management

Charge Capture in Healthcare, a critical component of the revenue cycle management process, involves the accurate and timely documentation of all services rendered to patients. This includes procedures, tests, medications, and other healthcare services. While it may seem like a simple task, effective healthcare charge capture is essential to ensure optimal revenue cycle performance and […]
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