Claims reimbursement
Providers rely on payer reimbursement to cover the costs of providing healthcare services. Without timely and complete reimbursement, providers may struggle to maintain operations. Effective claims management helps to reduce errors and minimize fraud risk while streamlining the reimbursement process to decrease denials.
Top Stories
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News
26 Sep 2024
Three-quarters of providers say claim denials increasing
The growing rate of claim denials poses a threat to healthcare revenue cycle management. Continue Reading
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11 Sep 2024
AMA 2025 CPT code set updates focus on novel genetic testing
The AMA's 2025 CPT code set has 420 updates, including new codes for genetic testing, AI medical services, remote therapeutic monitoring and novel surgical techniques. Continue Reading
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02 Dec 2022
AHA, AMA Urge Congress to Prevent Medicare PAYGO Sequester
Coupled with the 4.5 percent reduction in the Physician Fee Schedule, the 4 percent Medicare PAYGO sequester will result in an 8.5 percent payment decrease for physicians next year if Congress does not act. Continue Reading
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17 Nov 2022
Improper Payment Rate for Federally Facilitated Exchange Fell Under 1%
The majority of payments from the FFE were paid correctly in 2020, leading to an improper payment rate of just 0.62 percent, which amounted to $256 million. Continue Reading
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08 Nov 2022
Medicare, Medicaid DSH Payment Methods Exacerbate Racial Disparities
Counties with a significant share of Black residents had worse population health compared to other counties, despite receiving similar levels of DSH payments, highlighting structural racial disparities. Continue Reading
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01 Nov 2022
Medicare, Medicaid Payment Policies Inconsistent for Dual Eligibles
Providers may receive lower reimbursement when treating dual eligible beneficiaries due to inconsistent Medicare and Medicaid payment policies. Continue Reading
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24 Oct 2022
Hospital Reimbursement Boosts Access to Birth Control Postpartum
Medicaid can fill a major postpartum care gap by providing hospital reimbursement for the provision of long-acting reversible contraception while the patient is still inpatient. Continue Reading
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13 Oct 2022
CMS Will Apply Higher 340B Hospital Reimbursement Rate After Court Ruling
The court ruling comes after the Supreme Court struck down a nearly 30 percent cut to 340B hospital payments from 2018. Continue Reading
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05 Oct 2022
ED-ICU Model Maintains ED Costs, Improves Value of Healthcare Delivery
The ED-ICU model has the potential to improve the value of healthcare delivery, as it has been shown to improve care quality and have little impact on emergency department costs. Continue Reading
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03 Oct 2022
Medical Coding is the Next Stop for Artificial Intelligence in Healthcare
Industry leaders agree that artificial intelligence in healthcare is taking off; medical coding and billing is the latest use case for ER staffing company TECHealth. Continue Reading
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30 Sep 2022
OIG: CMS System Edits Reduced Medicare Overpayments to Hospitals
Medicare overpayments totaled $39.3 million between September 2016 and December 2021, but most of those improper payments occurred before CMS corrected its system edits error in May 2019. Continue Reading
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28 Sep 2022
Medical Groups May Reduce Staff, Patients Amid Medicare Payment Cuts
The potential Medicare payment cuts for 2023 reflect the proposed 4.5 percent decrease in the Medicare conversion factor and the 4 percent PAYGO sequester. Continue Reading
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15 Sep 2022
AMA, Other Medical Groups Go After Cigna Over Underpayments
The groups joined a class action lawsuit against Cigna, claiming that the private payer reimbursed providers in the MultiPlan network at lower rates than previously agreed upon. Continue Reading
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13 Sep 2022
State Surprise Billing Laws Impact Out-of-Network Provider Charges
Provider charges for out-of-network care increased by $1,157 after the passage of state surprise billing laws that allow arbitrators to consider provider charges in a surprise billing dispute. Continue Reading
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12 Sep 2022
AMA Releases 2023 CPT Code Set, Aims to Reduce E/M Coding Burden
The 2023 CPT code set will update the rest of the E/M code section after significant changes in 2021, as well as revise AI and virtual care codes. Continue Reading
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12 Sep 2022
How Time-Based Billing Impacts Physician Reimbursement for E/M Visits
For 90-minute new patient E/M visits and 45-minute return patient E/M visits, annual physician reimbursement was $409,894 under time-based billing and $188,065 under medical decision-making-based billing. Continue Reading
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07 Sep 2022
Physicians Slam Fee Schedule Cuts, Call for Medicare Payment Reform
Physician advocacy groups say the proposed fee schedule updates will harm patient access to care and cripple practices financially unless Congress passes Medicare payment reform. Continue Reading
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01 Sep 2022
8 New CPT Codes Added for Bivalent COVID-19 Booster Doses
AMA has added the new CPT codes in light of new bivalent COVID-19 boosters adapted to the omicron variant, which now makes up the majority of positive cases. Continue Reading
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05 Aug 2022
AHA Asks Federal Court to Immediately Stop 340B Payment Cuts
The motion comes after the Supreme Court unanimously agreed that 340B payment cuts dating back to 2018 are unlawful. Continue Reading
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04 Aug 2022
OIG: CMS Reported Collecting Only Half of Medicare Overpayments
Despite CMS reporting that it recovered $272 million in Medicare overpayments, OIG found that the agency only provided documentation for collecting $120 million. Continue Reading
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28 Jul 2022
AMA Announces CPT Code Update for Monkeypox Vaccines, Testing
The CPT code update includes codes for diagnostic testing, a smallpox vaccine, and a monkeypox vaccine. Continue Reading
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27 Jul 2022
How Hospitals, EDs Effectively Code Social Determinants of Health
Hospitals and emergency departments need to properly code for social determinants of health to improve tracking and reimbursement. Continue Reading
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26 Jul 2022
House Reps Ask HHS to Clarify Critical Access Hospital Payment Rule
Reinstating the 96-hour payment rule for critical access hospitals would require the facilities to discharge or transfer patients after 96 hours to receive reimbursement. Continue Reading
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18 Jul 2022
Hospitals Press CMS to Rethink Proposed FY23 Medicare IPPS Rates
Lawmakers are also urging CMS to use its authority to adjust FY23 Medicare IPPS rates, to prevent net decreases. Continue Reading
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06 Jul 2022
Claim Denial Rates as High as 80% for Some Marketplace Payers
A new analysis shows that claim denial rates for in-network services among Healthcare.gov marketplace payers varied significantly, with some as high as 80%. Continue Reading
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01 Jul 2022
AHA Calls for Timely Repayment to 340B Hospitals After Unlawful Cuts
In addition to issuing timely repayments to 340B hospitals, AHA urged HHS not to apply budget neutrality when determining an appropriate remedy. Continue Reading
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27 Jun 2022
Safety-Net Hospitals Lose Challenge of Medicare DSH Payment Rule
The Supreme Court sided with the government, upholding a 2004 rule that resulted in billions of dollars in cuts to Medicare DSH payments. Continue Reading
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22 Jun 2022
AHA Responds to Proposed FY23 Hospital IPPS Payment Updates
AHA said that the proposed payment updates in the Hospital IPPS rule do not reflect the inflationary environment in which hospitals and health systems are operating. Continue Reading
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17 Jun 2022
Medicare, Beneficiaries Saw Higher Prices at Provider-Based Facilities
The Medicare program and Medicare beneficiaries could have saved a combined $1.6 billion if provider-based facilities charged the same payment rate as freestanding facilities, OIG found. Continue Reading
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16 Jun 2022
Hospitals Win Supreme Court Case on 340B Reimbursement Cuts
HHS violated the Medicare statute when it implemented reimbursement cuts for hospitals participating in the 340B Drug Pricing Program, the Supreme Court determined. Continue Reading
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15 Jun 2022
AHA Opposes Proposed Payment Cut for Skilled Nursing Facilities
In addition to opposing the payment cut for skilled nursing facilities included in the SNF PPS proposed rule, AHA offered feedback on the new quality reporting measures CMS proposed. Continue Reading
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14 Jun 2022
Eliminating Indirect Billing for NPs, PAs Could Save Medicare $194M
Indirect billing makes it difficult to quantify and characterize the care nurse practitioners and physician assistants provide to patients at healthcare practices. Continue Reading
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02 Jun 2022
Are PBMs Unjustly Profiting from 340B Drug Pricing Program?
Contract pharmacies affiliated with pharmacy benefit managers are generating unjust profits from the 340B drug pricing program for corporations. Continue Reading
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23 May 2022
Hospital Groups Urge Courts to Enforce 340B Drug Pricing Requirement
Safety-net hospitals have experienced financial losses due to pharmaceutical companies refusing to comply with 340B drug pricing requirements and limiting discounts. Continue Reading
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20 May 2022
AMA Announces CPT Code for Moderna COVID-19 Vaccine for Young Kids
While the Moderna COVID-19 vaccine for young children has yet to receive FDA authorization, AMA has created a CPT code to ensure healthcare professionals are prepared for the shot’s potential use. Continue Reading
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19 May 2022
Hospital Prices 224% Higher for Private Payers than Medicare
Hospital prices for private payers varied by state, ranging from under 175 percent to over 310 percent of what Medicare would have paid for the same services. Continue Reading
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09 May 2022
Safety-Net Hospitals Lose $2.2M from 340B Drug Discount Limits
Sixteen drug companies have imposed 340B drug discount limits, making it harder for safety-net hospitals to access low-cost prescription drugs. Continue Reading
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04 May 2022
CA Doctor Sentenced in Medicare Fraud Scheme Involving Upcoding
In the Medicare fraud scheme, Donald Woo Lee billed Medicare $12 million for unnecessary vein ablation procedures by upcoding. Continue Reading
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Feature
29 Apr 2022
Breaking Down Common CMS Value-Based Payment Programs
To help improve patient health outcomes, CMS requires providers to participate in value-based payment programs, such as the Merit-Based Incentive Payment System and the Hospital Readmissions Reduction Program. Continue Reading
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27 Apr 2022
AMA Announces CPT Codes for Potential COVID-19 Boosters
The update adds CPT codes for a COVID-19 booster shot from Pfizer for children between 5 and 11 years old and a Sanofi-GSK booster for adults 18 years and older. Continue Reading
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06 Apr 2022
Hospital Prices Paid by Commercial Health Plans Varied Across US
Researchers found significant variation in hospital prices paid by commercial health plans, with some hospital regions seeing price increases while others in the same state saw decreases. Continue Reading
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31 Mar 2022
HHS Reduced Medicare Appeals Backlog by 88% During FY 2022 Q1
With the recent 88 percent reduction of the Medicare appeals backlog, HHS is on track to meet its court-ordered goal of clearing the backlog by the end of FY 2022. Continue Reading
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31 Mar 2022
Professional, Hospital E/M Charge Index Continued to Grow in 2021
In addition to the hospital E/M charge index rising, prices for professional evaluation and management, surgery, medicine, and radiology services increased last year. Continue Reading
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29 Mar 2022
Psychiatrists See Low Merit-Based Incentive Payment System Scores
Compared to other physicians, psychiatrists saw lower Merit-Based Incentive Payment System scores, suggesting that the value-based payment program does not accurately measure care quality for mental health providers. Continue Reading
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28 Mar 2022
Preventing Medical Necessity Denials With Clinical Documentation
In emergency medicine, physicians must provide care, and insurance payers are obligated to provide fair payment. But there's a growing trend of payment denials that physicians can only overcome with better documentation. Continue Reading
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25 Mar 2022
Global Hospital Budget Models May Help Curb Rising Hospital Prices
Global hospital budget models provide incentives for hospitals to manage patient volumes and costs within a budget constraint, helping to keep prices low. Continue Reading
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22 Mar 2022
AHA: Electronic Prior Authorization Implementation Requires Testing
AHA urged ONC to test electronic prior authorization processes in real-world settings before full implementation to ensure functionality and avoid practice disruptions. Continue Reading
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17 Mar 2022
AMA Urges Congress to Update Medicare Physician Payment System
The American Medical Association urged congressional leaders to lift the freeze on Medicare physician payments and provide updates that reflect inflation and practice costs. Continue Reading
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14 Mar 2022
Hospitals Saw Substantial Underbilling for Medicare Telestroke Services
One-third of hospitals across the country offered telestroke services, but less than 40 percent submitted Medicare telestroke claims in the year before the COVID-19 pandemic. Continue Reading
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10 Mar 2022
AHA Asks CMS to Waive Medicare Advantage Prior Authorization During PHE
CMS encouraged Medicare Advantage plans to waive prior authorizations during the public health emergency, but AHA urged the agency to make it a requirement instead of a suggestion. Continue Reading
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02 Mar 2022
High Hospital Prices Do Not Always Lead to Better Health Outcomes
In concentrated markets with little competition, high hospital prices reflected the lack of healthcare options and did not improve patient health outcomes. Continue Reading
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24 Feb 2022
Exploring the Fundamentals of Medical Billing and Coding
Medical billing and coding are the backbone of the healthcare revenue cycle, ensuring payers and patients reimburse providers for services delivered. Continue Reading
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23 Feb 2022
Specialty Pharmacies Offered Lower Drug Prices Than Hospitals
Drugs administered at a hospital cost $7,000 more than the same drugs did when patients obtained them through a specialty pharmacy. Continue Reading
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22 Feb 2022
Cost of Ground Ambulance Services Saw 22% Increase Since 2017
The price of ground ambulance services, which are not included in the No Surprises Act to prevent surprise billing, increased from $1,042 in 2017 to $1,277 in 2020. Continue Reading
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18 Feb 2022
Health Plan Automates Prior Authorization Process Using AI
By automating its prior authorization process with artificial intelligence, GuideWell aims to reduce administrative burden for providers and improve the patient experience. Continue Reading
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08 Feb 2022
Safety-Net Hospitals See Losses from 340B Drug Discount Limits
Twelve drug companies have imposed 340B drug discount restrictions, leading safety-net hospitals to experience significant financial losses. Continue Reading
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03 Feb 2022
Remote Work Propels Electronic Claims Management Adoption
Electronic claims management adoption increased by an average of 2.3 percentage points as healthcare providers shifted to remote work environments, CAQH reports. Continue Reading
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03 Feb 2022
States with More Uninsured Received Greater COVID-19 Treatment Funding
States with the largest uninsured populations received greater shares of COVID-19 treatment funding. However, states with Medicaid expansion used less than their share of funds. Continue Reading
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02 Feb 2022
AMA Updates CPT Codes for Pediatric COVID-19 Vaccine
The organization released new CPT codes for Pfizer’s pediatric COVID-19 vaccine once FDA grants emergency use authorization for children between six months and five years of age. Continue Reading
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24 Jan 2022
AMA Challenges MedPAC Suggestion to Freeze Medicare Physician Payment
The industry group states that a Medicare physician payment freeze would hinder the delivery of high-quality care as providers face financial burdens. Continue Reading
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24 Jan 2022
Key Ways to Improve Access to Claims Data for a Smoother Revenue Cycle
Claims data access is a major obstacle for providers, impacting revenue cycle management. With the right technology, providers can reap the benefits of electronic claims payment adoption. Continue Reading
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20 Jan 2022
More Pharma Companies Limit 340B Discounts to Safety-Net Hospitals
Bristol Myers Squibb is the latest pharmaceutical company to limit 340B discounts to safety-net hospitals using contract pharmacies to distribute medications to patients. Continue Reading
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19 Jan 2022
MedPAC Recommends Hospital Reimbursement Increase
The advisory committee will recommend that Congress increase hospital reimbursement for both inpatient and outpatient services in FY 2023. Continue Reading
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17 Jan 2022
Electronic Payment Key to Streamlining Healthcare Claims Management
Adopting electronic payment and remittance is a crucial step to streamlining healthcare claims management and getting patients their bills faster. Continue Reading
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14 Jan 2022
CPT Code for Third Dose of Pediatric COVID-19 Vaccine Added
AMA updated the CPT code for the third dose of Pfizer’s pediatric COVID-19 vaccine on the heels of the FDA’s recently expanded emergency use authorization. Continue Reading
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13 Jan 2022
Patient-Driven Payment Linked to a Decrease in SNF Therapy Utilization
A recent study assessed if implementation of the Patient Driven Payment Model impacted therapy utilization and health outcomes of patients admitted to skilled nursing facilities. Continue Reading
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10 Jan 2022
R1 RCM to Acquire Cloud-Based Healthcare Revenue Company Cloudmed
The healthcare revenue cycle management solutions company will acquire Cloudmed in an all-stock transaction valued at $4.1B. Continue Reading
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10 Jan 2022
Why Claims Payment Optimization is Crucial for Providers
Most claims payments are now electronic, but providers can still realize millions in cost savings and reduce burden through true claims payment optimization. Continue Reading
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07 Jan 2022
COVID-19 Tests Spike Growth in Medicare Spending
Medicare Part B spending on clinical diagnostic laboratory (lab) tests increased by 4.2 percent, impacted by new spending on COVID-19 tests. Continue Reading
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Feature
29 Dec 2021
Top Healthcare Fraud, Waste, and Abuse Takedowns of the Year
Here are some of this year’s largest healthcare fraud, waste, and abuse takedowns as reported by the Department of Justice. Continue Reading
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28 Dec 2021
Hospital Prices for Most Services Less than Payer-Negotiated Rates
A recent study found that hospital prices for self-pay patients are often lower than commercial prices negotiated with payers, but not all cash prices have been disclosed. Continue Reading
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20 Dec 2021
Providers Dodged Major Medicare Payment Cuts But More Work To Be Done
Healthcare providers are still up against significant Medicare payment cuts, including ones postponed by Congress, as well as financial losses from the pandemic. Continue Reading
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17 Dec 2021
In-Network, Complex COVID-19 Hospitalizations Cost More Than $128K
COVID-19 hospitalization costs varied by state, with the highest in-network cost averaging $128,650. Continue Reading
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14 Dec 2021
American Renal, Former Execs Charged with Healthcare Fraud Scheme
The SEC charged the dialysis provider and three former executives with a healthcare fraud scheme involving revenue manipulation. Continue Reading
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13 Dec 2021
Impact of Future Medicare Cuts on Physician Reimbursement
Physician reimbursement under Medicare has remained stagnant for decades, and without legislative intervention, payments will be significantly reduced again in 2022. Continue Reading
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10 Dec 2021
Legislation Stopping Medicare Payment Cuts Clears Congress
The House and Senate have passed legislation that will prevent Medicare payment cuts by extending the pause on Medicare and PAYGO sequester reductions. Continue Reading
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09 Dec 2021
AMA, AHA Sue Feds Over No Surprises Act Final Rule
The hospital and physician groups filed lawsuit against the federal government over a No Surprises Act final rule that will implement the independent dispute resolution process. Continue Reading
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08 Dec 2021
House Dems Look to Prevent Medicare Payment Cuts
The group of House Representatives called on the President and Congress to prevent looming Medicare payment cuts for physicians and hospitals. Continue Reading
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06 Dec 2021
COVID-19 Associated with $13.9B Decline in Medicare Spending
A new report found that Medicare spending on physician services dropped $13.9 billion in 2020 due to changes in utilization caused by COVID-19. Continue Reading
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03 Dec 2021
Providers Accuse NC Payer of Abusing No Surprises Act, Cutting Rates
A physician group accused BlueCross BlueShield of North Carolina of abusing the No Surprises Act by using “strong arm” tactics on clinicians to lower in-network rates. Continue Reading
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02 Dec 2021
Hospital Groups Want Congress to Delay 2% Medicare Sequester Cuts
Several hospital groups call on members of Congress to prevent upcoming Medicare sequester cuts and Statutory Pay-As-You-Go (PAYGO) cuts. Continue Reading
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01 Dec 2021
HHS Report: State Surprise Billing Laws Offer Limited Protection
Surprise billing is common among privately insured consumers and while most states have laws to address the issue, the laws do not go far enough to protect most people, HHS reports. Continue Reading
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16 Nov 2021
Medicare FFS Improper Payment Rate Hits Low of 6.26%
2021 marks the fifth consecutive year that the Medicare fee-for-service (FFS) improper payment rate has been below the 10% threshold, CMS announced. Continue Reading
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15 Nov 2021
Automatic MIPS Participation Exemption for Individual Eligible Clinicians
MIPS participation is optional for individual eligible clinicians in PY 2021 because of the ongoing COVID-19 pandemic, CMS recently announced. Continue Reading
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11 Nov 2021
Out-of-Pocket Costs Less When Hospitals Don’t Bill Insurance
Patients can reduce their out-of-pocket costs by paying discounted cash price offered by hospitals instead of going through their insurance. Continue Reading
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05 Nov 2021
Geisinger to Pay $18M Settlement Over Medicare Billing Violations
Geisinger Community Health Services settled with the federal government after uncovering Medicare billing violations involving home health services. Continue Reading
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03 Nov 2021
40% of Charges for COVID-19 Services Initially Ended in Claim Denials
Other common reasons for claim denials in the first 10 months of 2021 included errors related to bundling, eligibility/registration, and adequacy of information provided. Continue Reading
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01 Nov 2021
CMS Updates End-Stage Renal Disease APM, PPS to Address Health Equity
The End-Stage Renal Disease (ESRD) Treatment Choices Model is the first to undergo changes to directly address health equity—a new goal for CMS-run alternative payment models. Continue Reading
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28 Oct 2021
Nearly $27B Remains in Provider Relief Fund, Analysis Shows
Many healthcare providers are still waiting on grants from the Provider Relief Fund as the COVID-19 pandemic rages on. Continue Reading
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28 Oct 2021
CPT Code Set Adds Code for J&J COVID-19 Vaccine Booster
AMA updated the CPT code set to accommodate the new mix-and-match COVID-19 vaccine booster strategy endorsed by the federal government. Continue Reading
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27 Oct 2021
Prior Authorizations Beat COVID Workplace as Top Regulatory Burden
An overwhelming majority of medical groups say regulatory burden is increasing, with prior authorization requirements, COVID-19 workplace mandates, and MIPS topping their list of problems. Continue Reading
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25 Oct 2021
High-Impact CARES Act Funds Were Disproportionately Distributed
The majority of high-impact CARES Act Funds went to hospitals that were financially stable before the COVID-19 pandemic hit, a study found. Continue Reading
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22 Oct 2021
AHA Calls for Medicare Advantage Inclusion in Prior Authorization Rule
AHA wants CMS to include Medicare Advantage in its proposed prior authorization rule that would expedite the prior authorization process and reduce delays in patient care. Continue Reading
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21 Oct 2021
COVID-19 Hospitalizations Can Cost Over $100K, If Out of Network
Non-complex COVID-19 hospitalizations are running up hundreds of thousands of dollars in costs when delivered outside of a patient’s network, especially in western states. Continue Reading
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19 Oct 2021
Escalating Risk, Reward of the Merit-Based Incentive Payment System
Changes are coming to the Merit-Based Incentive Payment System. Providers should prepare now for greater risk and reward. Continue Reading
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14 Oct 2021
How E/M Coding Changes Became an Urgent Problem for a TN Clinic
AFC Urgent Care Memphis was not only hit with revenue losses from COVID-19 but also E/M coding changes. A new medical coding and billing strategy boosted revenue by 25%. Continue Reading
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12 Oct 2021
Telehealth Reimbursement Needed to Address Demand, Staffing Issues
About 41% of primary care clinicians say going back to pre-pandemic telehealth reimbursement rules would kill virtual care at their practices and exacerbate staffing issues. Continue Reading
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News
11 Oct 2021
Most Group Practices Received Positive MIPS Scores For 2020 Payments
Despite stricter score thresholds, most group practices received positive MIPS scores in 2018 which led to increased 2020 payment rates. Continue Reading
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07 Oct 2021
AMA Issues CPT Codes for Pediatric Doses of Pfizer COVID-19 Vaccine
To prepare for potential FDA authorization, AMA has released new CPT codes for pediatric doses of the Pfizer COVID-19 vaccine. Continue Reading
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News
05 Oct 2021
Air Ambulance Prices Rose Substantially for Commercially Insured
The average estimated in-network amount for fixed-wing air ambulance transport increased by 76% from 2017 to 2020 alone, a new analysis finds. Continue Reading
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04 Oct 2021
Surprise Billing Regulation a Gift to Payers, Blow to Providers
Healthcare industry groups representing providers are upset with the latest surprise billing regulation detailing the independent dispute resolution process. Continue Reading
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04 Oct 2021
HHS Removes 79% of Medicare Appeals Backlog, On Track for FY 2022
HHS reduced the Medicare appeals backlog by 79 percent during the third quarter of FY 2021, putting the department ahead of schedule to clear the backlog. Continue Reading