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.
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By Kajol Shah – Healthcare organizations are moving quickly from AI pilots to AI-enabled workflows. What began as administrative chatbots and documentation support is now expanding into AI agents that can assist with scheduling, intake, patient communication, clinical documentation, revenue cycle tasks, and information retrieval across connected systems.
By Dr. Muhammad Numan – Every week, medical billing errors cost U.S. healthcare organizations millions of dollars. Put that on a yearly scale and the numbers add up fast. According to one estimate, U.S. providers lose over $262 billion annually to revenue cycle inefficiencies alone.
By Sanjay Subramanian – 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.
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.
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.