Tag: Prior Authorization

Prior Authorization Challenges

5 strategies to address Prior Authorization Challenges

Prior Authorization Challenges are a growing hurdle for medical practices dealing with Medicare Advantage plans. Recent investigations reveal concerning trends: improper denials and a lack of transparency from some insurers. This can significantly delay or even block essential care for patients. The Problem with Prior Authorizations Improper Denials: A government investigation found that Medicare Advantage […]
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healthcare denied claims impact and appeals

Unlocking the Secrets of Denied Claims: Insights, Solutions, and Strategies

The Prime Minister’s recent voluntary national survey shed light on the Denied claims. The survey, conducted between October and December 2023, found that nearly 15% of all Medicare Advantage, Medicaid, Commercial and Managed Medicaid claims were denied. Between 45% and 60% of rejected cases were overturned, although the expensive appeals process sometimes meant multiple appeals. […]
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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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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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Value-Based-Care-in-2024

Advances in AI and Technology for Efficient Value-Based Care 2024

Value-based care in 2024: As 2024 approaches, healthcare is undergoing unprecedented innovation and digital transformation. Emerging technologies and capabilities are empowering organizations, including payers, providers, and self-funded employers, to confidently embrace risk within value-based care programs. The American Academy of Family Physicians reports that 49% of practices participate in some form of value-based payment, and […]
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Darker side of AI in healthcare

AI in Healthcare: Revealing the Risks and Challenges Ahead

AI represents a promising frontier, especially in healthcare, where leveraging vast information could revolutionize problem-solving. However, a shadow looms over AI, as anticipated by many. In the realm of health insurance and patient care denials, AI has already stirred controversy, leading to a notable class action lawsuit. According to reports from healthcare News, Health Insurance […]
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Key-Survey-findings-common-causes-of-healthcare-claim-denials

Key Survey Findings: Common Causes of Healthcare Claim Denials

According to a recent survey, eligibility and prior authorization issues were among the most prevalent causes of claim denials. Hospitals and healthcare systems are experiencing an uptick in claim rejections due to errors in front-end revenue cycle processes. The Healthcare Financial Management Association’s Pulse Survey program, conducted for a healthcare technology company, gathered responses from […]
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Advancing Prior AuthorizationThe Evolution in CMS Regulation

Advancing Prior Authorization: The Evolution in CMS Regulation

The Centers for Medicare & Medicaid Services (CMS) have embarked on a decisive move by enforcing a standard for Advancing prior authorization. In a conversation with the Senior Director of Utilization Management, we discussed the potential implementation and impact of this proposed mandate, slated for enactment in January 2026 The Predicament of Prior Authorization The […]
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The Impact and Challenges of Medicare Advantage (MA) for Payers and Providers

The Impact and Challenges of Medicare Advantage for Payers and Providers

Medicare Advantage (MA) is becoming more appealing to payers due to its numerous benefits, but providers are struggling to adjust to its effects. Payers are increasingly recognizing the advantages of MA, especially in terms of profitability. According to a study conducted by the Kaiser Family Foundation (KFF), MA insurers disclosed an average gross margin of […]
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