Our recent articles provide new perspectives and expert insights

 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...

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...

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...

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...

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)...

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...

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...

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...

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....

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...