By Anne Neal – For years, the industry has measured payment integrity success largely through recoveries, savings, and avoided overpayments. However, achieving those metrics often comes at the cost of significant abrasion that manifests as claims rework, provider tension, cash flow unpredictability, and poor member experience.
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By Syed Sibt-e-Hassan – Most practices judge a good month by the balance in the bank. It is the slowest and least useful way to understand revenue. By the time a shortfall shows up in the account, its causes are weeks old and often past the point of recovery.
By Rafiq Ahmed – For decades, one of the most consequential numbers in healthcare was effectively invisible to the providers delivering care: what a payer actually reimburses a hospital for a given service. Health systems negotiated contracts based on internal assumptions, historical precedent, and incomplete intelligence about what the market was actually paying.
By Tyler Cobb – A certificate of insurance is a one-page summary issued as a convenience. It is not a policy, it confers no rights, and it says almost nothing about whether the endorsements behind it actually match what the contract requires. Third-party risk has become a primary exposure pathway for provider organizations.
By Jerry Smith – Drug affordability conversations often center on manufacturers and their high list prices. This focus overlooks the real cost driver: the complex pharmaceutical ecosystem.
By Megan Schmidt – Healthcare is spending billions to modernize the future while ignoring one of its most expensive operational failures. Provider data, the foundational information that determines who gets paid, where patients receive care, and how networks function, remains inaccurate across much of the industry.
Reported payers and health insurance industry news from UnitedHealthcare, RevSpring, PatientGenie, Anthem Blue Cross and Blue Shield, CareFirst BlueCross BlueShield, Aetna, GoHealth and more.
By Michael Ford – A growing share of the problem hospitals face today doesn’t come from denials at all. It comes from claims that sit unresolved without ever receiving a formal denial. Why do these claims fall through the cracks?
By April Miller – Healthcare organizations face financial pressure as operating costs and administrative demands increase. At the same time, patients expect clear pricing and greater transparency throughout the billing process.