By Sanjay Subramian – Why Real-Time Approval Requires Rethinking Payer Infrastructure – Prior authorization exists for a reason; it requires providers to obtain approval from a patient’s health plan before certain services or treatments are delivered. Insurers view it as a way to confirm medical necessity and control costs.
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Reported payers and health insurance industry news from United Healthcare, Aetna, Anthem Blue Cross and Blue Shield, Independence Blue Cross, CareFirst BlueCross BlueShield, Cigna Healthcare, AHIP, CareSource, and more.
By Nathan Turock – The revenue cycle management industry has spent a decade and billions of dollars building better billing engines, smarter clearinghouses, more sophisticated denial management tools, and most recently autonomous AI coders. And yet, 450 million claims are still denied every year in the United States.
By Matt Saucedo – Home health agencies are losing revenue they have already earned, not from denied claims or underpayment disputes, from billing gaps that never surface on a financial statement. The problem is structural. Most home health agencies run on cash basis accounting. Revenue appears when the check arrives, not when care is delivered.
The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model makes progress toward that goal by piloting outcome-based payments for technology-enabled care of several chronic diseases, including behavioral health, musculoskeletal conditions, and cardio-kidney-metabolic conditions.
Reported payers and health insurance industry news from Aetna, UnitedHealthcare, Blue Cross Blue Shield Association, CareFirst BlueCross BlueShield, Humana, AHIP, and more.
By Matt Seefeld – Behind staffing shortages and reimbursement pressure lies another challenge: complex billing workflows that force small teams to spend valuable time chasing payment instead of delivering care.
By Noah Breslow – For a long time, hospitals could count on one thing: even when reimbursement was complicated, it was still mostly predictable. Care was delivered, claims were submitted, and while denials happened, revenue generally followed. That is no longer the case.
Reported payers and health insurance industry news from Aetna, UnitedHealthcare, Cigna, Humana, AHIP, HHS and more.