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.
Read More
By Alicia Arrick – AI is no longer a futuristic concept. It’s here, and it’s reshaping everything from claims processing to radiology. But with great power comes the great responsibility of safeguarding the integrity, privacy, and security of healthcare data in a rapidly evolving digital landscape.
By Mohammed Vaid – Penalties reduce revenue, but their real significance lies in what they reveal about payer operations. A single error in plan materials can cascade into thousands of disputes, costly claim adjustments, and delayed reimbursements.
The Sequoia Project, a leading non-profit focused on advancing healthcare interoperability, is pleased to publish the “Payer-to-Payer Compliance Readiness Checklist.” This checklist is designed to help payers assess their readiness for compliance with the payer-to-payer components of CMS-0057-F, a critical regulation for improving data sharing and interoperability in healthcare.
By Joan Butters – A KFF survey from 2023 revealed nearly one in five adults had health insurance claims denied in the previous year. On a national level, that suggests millions of disaffected patients. The growing public frustration with the cracks in our healthcare industry has exploded into a national conversation.
By Ram Krishnan – Navigating payer stipulations in behavioral healthcare can be a challenge, as they are often more complicated than those for physical healthcare. However, understanding how to maintain compliance and bill properly is something that behavioral health clinicians and practice owners have to do to maintain business efficiency, avoid revenue losses, and provide timely care to patients.
By Stephanie Fraser – At HIMSS25, a distinguished panel of health plan leaders gathered to discuss how payers are moving beyond fee-for-service models and embracing AI, digital health and value-based care to advance patient outcomes and drive system-wide transformation.
By Amit Shah – HEDIS is a measurement set used to determine the efficacy of a payer to care for its members. The performance data collected through HEDIS assists payers in identifying areas for improvement as well as tracking successes through a measurement set that allows them to be compared to other payers.
By Misty Graham – Key stakeholders in the healthcare industry, including health plans, clinical data registries, and accountable care organizations, must collaborate to improve health outcomes, enhance patient experiences, manage chronic diseases, and provide better access to care while keeping costs low.