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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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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30 Sep 2021
Difference Between Clean Claims, Initial Claim Denials Key Hospital KPI
A new survey found that nearly 80% of hospitals measure the difference between clean claims and initial claim denial rates. Continue Reading
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23 Sep 2021
Complex COVID-19 Hospitalizations Cost an Average of $300K
While the previously estimated cost for COVID-19 hospitalizations was around $20,000, new data suggests that costs can range up to 15 times that figure. Continue Reading
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22 Sep 2021
Financial Incentives for Medical Assistants May Improve Care Delivery
Financial incentives for medical assistants may lead to increased effort and improved population health outcomes, a new study found. Continue Reading
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21 Sep 2021
High Healthcare Spending Shifts to Uninsured, Prescription Drugs
A small portion of the US population drives the most healthcare spending, but the concentration of that spending has shifted over the last 18 years, a study finds. Continue Reading
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20 Sep 2021
Employers to Leverage Hospital Price Transparency to Lower Rates
Employers state in a new report that new hospital price transparency requirements will help them to lower reimbursement rates as long as CMS ups enforcement efforts. Continue Reading
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20 Sep 2021
Medical Coding Slip at TX Hospital Led to COVID-19 Billing Error
A medical coding mistake caused Midland Memorial Hospital to allegedly submit claims to HRSA for uninsured patients without a COVID-19 diagnosis. Continue Reading
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15 Sep 2021
The Impact the Unvaccinated Are Having on Healthcare Spending
New data points to preventable healthcare spending on the treatment of unvaccinated individuals, including avoidable hospital stays. Continue Reading
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13 Sep 2021
CMS to Start Reprocessing Site-Neutral Outpatient Claims
The agency will reimburse patients who paid higher rates for outpatient services to comply with its site-neutral payment policy. Continue Reading
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09 Sep 2021
Revenue-Based COVID-19 Funds Failed to Help Some Hospitals in Need
A new study shows that distribution of Provider Relief Funds based on patient revenue did not help to support hospitals across some racial, ethnic, and social lines. Continue Reading
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08 Sep 2021
Hospitals Still Waiting on Remaining COVID-19 Provider Relief Funds
With billions still sitting in the COVD-19 Provider Relief Fund, the AHA is urging HHS to distribute federal funding to hospitals and health systems, especially those in rural areas. Continue Reading
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07 Sep 2021
2022 CPT Code Set Released, Streamlines Medical Coding for COVID-19
AMA released the 2022 CPT code set, which includes new medical coding and documentation standards for COVID-19 vaccinations, among other updates. Continue Reading
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07 Sep 2021
AMA Updates CPT Codes for COVID-19 Vaccines
The updates include unique CPT codes for a new formulation of the COVID-19 vaccine developed by Pfizer and new codes for booster doses expected to roll out later this month. Continue Reading
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06 Sep 2021
How Has COVID-19 Impacted Medicare Spending, Solvency?
The most recent report from Medicare’s Board of Trustees shows how the COVID-19 pandemic impacted Medicare spending and when the program’s trust fund will no longer be solvent. Continue Reading
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02 Sep 2021
AMGA Pushes Congress to Prevent 10% Medicare Payment Cut
The industry group urged lawmakers to stop proposed cuts to Medicare payment for physicians as outlined in recent legislation and regulation. Continue Reading
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01 Sep 2021
Risk-Based Revenue Stalls Despite Challenges with Fee-For-Service
The COVID-19 pandemic shone a light on the shortcomings of a fee-for-service system, yet progress toward more risk-based revenue has seemed to stall, a survey shows. Continue Reading
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25 Aug 2021
COVID-19 Workflows Improve Medical Coding Efficiency Beyond Pandemic
A system in Kansas is leveraging workflows designed to streamline COVID-19 vaccinations to improve medical coding efficiency beyond pandemic-related care. Continue Reading
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23 Aug 2021
NYT Slams Hospital Price Variation After Price Transparency Rule
A recent report featured in The New York Times highlights significant hospital price variation now that facilities must post costs under a new price transparency rule. Continue Reading
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16 Aug 2021
OIG: Medicare Overpays for Chronic Care Management Services
An OIG audit revealed millions in Medicare overpayments for chronic care management, sometimes at the expense of beneficiaries. Continue Reading
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13 Aug 2021
Medicare Reimbursement Available for Third Dose of COVID-19 Vaccine
CMS said it will continue to pay providers the national average Medicare reimbursement rate for administering a dose of a COVID-19 vaccine. Continue Reading
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11 Aug 2021
Telehealth Claim Lines Stabilize After Months of Decline
Telehealth claim lines stabilized at about 5% in May 2021 after falling nationally each month from February to April of this year, FAIR Health reports. Continue Reading
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22 Jul 2021
GAO Pushes HHS to Reveal Plans for Unused Provider Relief Funds
About 25% of Provider Relief Fund appropriations remain unobligated and HHS has not provided time frames for distribution of these unused COVID-19 funds, GAO found. Continue Reading
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20 Jul 2021
Hospital Pros and Cons of the CY 2022 OPPS Proposed Rule
Hospital groups are digesting the 863-page CY 2022 OPPS proposed rule, but many are already commenting on new hospital price transparency penalties and other policies. Continue Reading
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15 Jul 2021
AI Helps Hospitals Predict DRG-Based Claims Reimbursement, Costs
Researchers developed an artificial intelligence model to predict claims reimbursement and hospital costs based on DRG shortly after inpatient admission. Continue Reading
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14 Jul 2021
The Good and Bad of the Medicare Physician Fee Schedule Proposal
Industry groups are already criticizing the CY 2022 Medicare Physician Fee Schedule proposed rule, identifying what policies they think would benefit practices or those that would not. Continue Reading
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07 Jul 2021
Moving to the Future of Clinical Documentation Improvement
Michigan Medicine’s chief revenue officer sees ambient technology as the future of clinical documentation improvement, so the system is taking steps now to reach that. Continue Reading
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06 Jul 2021
340B Drug Payment Case Heads to Supreme Court
The US Supreme Court has elected to hear a case challenging Medicare’s cuts to 340B drug payments to hospitals. Continue Reading
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29 Jun 2021
Supreme Court Will Not Hear Site-Neutral Payment Case
The Supreme Court has declined to hear a case brought on by hospital groups seeking to stop site-neutral payment rates for outpatient clinic visits. Continue Reading
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28 Jun 2021
Hospitals Offer Suggestions for Surprise Billing Law Implementation
New details on implementation of the No Surprises Act are forthcoming, so FAH provided some recommendations on how to eliminate surprise billing. Continue Reading
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24 Jun 2021
Providers Still Want More Time to Spend COVID-19 Relief Funds
HHS recently extended the deadline to use COVID-19 relief funds to the end of the month, but some providers say they still need more time. Continue Reading
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24 Jun 2021
HRSA: Over 5M Claims Paid for Uninsured COVID-19 Vaccinations
Reimbursement for the uninsured COVID-19 vaccination claims is part of the Biden-Harris administration’s to create equitable access to COVID-19 vaccines. Continue Reading
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17 Jun 2021
AMA Calls for Suspension of Prior Auths During PHEs, Better Peer Reviews
The requests are among several policies AMA adopted at a Special Meeting aimed at streamlining the prior authorization process, especially around peer-to-peer reviews. Continue Reading
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07 Jun 2021
Over Third of Hospital Execs Report Claim Denial Rates Nearing 10%
Average claim denial rates are between 6% and 13%, but some hospitals are nearing a “danger zone” after COVID-19, a survey shows. Continue Reading
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07 Jun 2021
Before COVID-19, Healthcare Spending Increased by 4.6%
An acceleration in personal healthcare spending, especially on hospital care and prescription drugs, contributed to the growth, AMA reports. Continue Reading
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04 Jun 2021
AHA Launches Hospital Revenue and Claims Comparison Tool
The AHA’s Vitality Index allows hospitals to compare hospital revenue performance with peers and track claims and reimbursements. Continue Reading
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02 Jun 2021
Medicare Claims Data Show Health Disparities in COVID-19 Patients
COVID-19 Medicare spending shows higher financial burdens for rural residents and non-White patients, reveals a new study analyzing Medicare claims data. Continue Reading
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27 May 2021
HHS: $4.8B to COVID-19 Testing Reimbursement for the Uninsured
HHS will designate $4.8B from the American Rescue Plan to COVID-19 testing reimbursement under the HRSA COVID-19 Uninsured Program. Continue Reading
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19 May 2021
Site-Neutral Payment Case Lacks Merit, HHS Tells Supreme Court
The federal department also asked the Supreme Court to not review the site-neutral payment case brought on by hospitals challenging lower rates for outpatient E/M services. Continue Reading
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07 May 2021
Medicare Payment Bumped for COVID-19 Antibody, At-Home Infusions
CMS has raised the Medicare payment rate for administering certain COVID-19 antibody infusions, which can now be delivered in patient homes. Continue Reading
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05 May 2021
CPT Codes Created for Novavax COVID-19 Vaccine, Administration
The CPT code is the fifth created for providers to document and bill for the administration of COVID-19 vaccines, AMA announced. Continue Reading
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05 May 2021
HHS Paying Providers for Underinsured Vaccine Administration
A new program will reimburse providers for administering vaccines to patients enrolled in health plans that do not cover the service or cover with patient cost-sharing, HHS announces. Continue Reading
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27 Apr 2021
CT Physicians Accused of “Price Gouging” COVID-19 Tests
Cigna is accusing a group of physician practices of inflating COVID-19 test prices after the practices sued over denied reimbursement. Continue Reading
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22 Apr 2021
AHA, Hospital Groups Continue Fight Over 340B Drug Discounts
Leading hospital groups have asked the new HHS Secretary to stop six major pharmaceutical companies from denying 340B drug discounts. Continue Reading
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20 Apr 2021
AHA: Site-Neutral Medicare Reimbursement May Limit Access To Care
Medicare patients who receive care at hospital off-campus departments are more likely to be sicker and poorer than those at physician offices. Continue Reading
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19 Apr 2021
2% Medicare Sequester Cuts Delayed Through End of 2021
CMS has announced suspension of the Medicare sequester cuts will last through Dec. 31, 2021, and it will release all claims held since the start of April. Continue Reading
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14 Apr 2021
Coalition Urges CMS to Rethink Medicare Prior Authorization Growth
The coalition of 40 healthcare industry groups is challenging Medicare prior authorization growth finalized in recent hospital OPPS and ASC final rules. Continue Reading
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13 Apr 2021
Prior Authorization Burden Still High Despite COVID Struggles
85% of physicians say prior authorization burden was high or extremely high in 2020 and that payer policy changes during the COVID-19 pandemic were limited. Continue Reading
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12 Apr 2021
Policy, Regulation Shaping Emergency Medicine Reimbursement
New surprise medical billing rules, expiration of temporary waivers, and other health policies and regulation will impact emergency medicine reimbursement in the future. Continue Reading
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06 Apr 2021
OIG Asks Hospital for $23.6M Back After Medicare Billing Errors
The HHS watchdog identified overpayments reimbursed to Sunrise Hospital & Medical Center from years of Medicare billing errors, including for IRF claims. Continue Reading
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05 Apr 2021
CMS Starts Recouping Accelerated, Advance Medicare Payments
The agency has begun recoupment of accelerated and advance Medicare payments from providers who borrowed the emergency funds one year ago to battle COVID-19. Continue Reading
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02 Apr 2021
Hospital Outpatient Payment Would Suffer If 340B Cuts Reversed
A new analysis showed that 82% of OPPS hospitals would see net total outpatient payment decreases if HHS reversed significant cuts to 340B drug reimbursement. Continue Reading
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01 Apr 2021
CMS Holding Claims Until Medicare Sequester Decision
MACs will temporarily hold claims from April 1 on in the event Congress decides to extend the suspension of the 2% Medicare sequester through legislation. Continue Reading
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30 Mar 2021
AHA Asks CMS to Rescind Site-Neutral Payment Exception Denials
The hospital group says CMS should rescind recent audit determinations denying hospitals a mid-build exception to site-neutral payment under the 21st Century Cures Act. Continue Reading
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29 Mar 2021
Mass. Healthcare Spending Increases, Premiums, Cost-Sharing Slow
Massachusetts’ 2019 healthcare spending exceeded the annual growth benchmark, while premiums and cost-sharing decreased for commercial members. Continue Reading
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23 Mar 2021
Contactless Payments, Virtual Care Surge To Continue Post-COVID-19
Consumers reported positive experiences with the COVID-19 virtual care and contactless payment boom, highlighting the need for continued innovation. Continue Reading
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22 Mar 2021
Providers Try to Stave Off Looming Medicare Spending Cuts
Several leading industry groups have called on Congress to prevent up to $36 billion in Medicare spending cuts triggered by recent legislation actions. Continue Reading
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22 Mar 2021
Hospital Medicare Payments Dwarf Surgical, Add to Price Hikes
Paradoxically, as length of stay has decreased for hip fracture Medicare beneficiaries, hospital reimbursement has gone up over the past decade. Continue Reading
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17 Mar 2021
2% Hospital Reimbursement Hike, Other 2022 MedPAC Recommendations
The hospital reimbursement increase should also come with quality incentive program revisions, while physician rates should stay the course, according to the March report to Congress. Continue Reading
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15 Mar 2021
CMS Boosts Medicare Reimbursement for COVID-19 Vaccinations
Medicare reimbursement rates will nearly double for the administration of single- and two-dose vaccines. Continue Reading
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10 Mar 2021
MA Reimburses 2X Medicare Rate for Some COVID-19 Vaccinations
Governor Baker has agreed to reimburse healthcare providers twice the national Medicare rate for COVID-19 vaccinations to accelerate vaccine rollout. Continue Reading
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09 Mar 2021
Skilled Nursing Facility Staffing Impacted by New Payment Rules
Skilled nursing facility staffing decreased after Medicare implemented the Patient Driven Payment Model, with physical therapy and occupational therapist assistant levels dropping the most. Continue Reading
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08 Mar 2021
AMA: Medicare Sequester Threatens Physician Practice Viability
Congress should extend the Medicare sequester moratorium and prevent the triggering of additional cuts from the final passage of the American Rescue Plan Act, AMA said. Continue Reading
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08 Mar 2021
Major Physician Reimbursement Gap for Independent Versus Hospital Docs
A new study shows that Medicare physician reimbursement would have been $114K higher per physician a year if the doctor was integrated with a hospital system. Continue Reading
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05 Mar 2021
Physician Specialties Hit Hardest by Medicare Spending in 2020
Medicare spending on physician services decreased by $9.4B in the first half of 2020, but some physician specialties, services, and settings were hit harder than others. Continue Reading
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03 Mar 2021
Hospital Uncompensated Care Costs Down After LA Medicaid Expansion
The findings suggest that Medicaid expansion in Louisiana—the only Deep South state to leverage the policy—could be a model for remaining non-expansion states. Continue Reading
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02 Mar 2021
Reimbursing at Medicare Rates to Cut Healthcare Spending by $352B
Lowering private payer reimbursement to Medicare rates would significantly reduce rising healthcare spending but would slash hospital and other provider revenue. Continue Reading
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02 Mar 2021
Biden Administration Recommits to COVID-19 Reimbursement
The administration said it will provide COVID-19 reimbursement to providers treating uninsured patients and banned health plans from charging for COVID-19 tests. Continue Reading
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26 Feb 2021
Hospitals Increasingly Billing Inpatient Stays at Highest Severity
The number of inpatient stays billed at the highest severity level increased by nearly 20% from FY 2014 to FY 2019, suggesting a need for additional oversight, OIG reported. Continue Reading
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25 Feb 2021
COVID-19 Hospital Revenue Losses Could Reach Up to $122B in 2021
Hospital revenue is slated to be down between $53B to $122B compared to pre-pandemic levels because of COVID-19, potentially impacting vaccination efforts. Continue Reading
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23 Feb 2021
Hospital Price Transparency to Save Just $8.7B to $26.6B a Year
Even $8.7B in savings from hospital price transparency is a lot, but that is in comparison to $1.3T in total hospital spending; other policy strategies may be more effective. Continue Reading
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15 Feb 2021
States Make Progress with Telehealth Reimbursement Laws
More states have laws addressing telehealth reimbursement, and many in 2021 are expected to make additional efforts, according to lawyers from Foley & Lardner. Continue Reading
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11 Feb 2021
Hospitals Ask Supreme Court to Take Up 340B, Site-Neutral Payments
The organizations filed petitions calling on the Court to reverse court decisions that upheld a hospital outpatient site-neutral payment policy and 340B cuts. Continue Reading
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10 Feb 2021
Primary Care Needs Telehealth Reimbursement, Targeted Relief
From continued telehealth reimbursement to more targeted federal relief, primary care practices need payment reform to survive the second year of the COVID-19 pandemic. Continue Reading
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10 Feb 2021
Medicaid Physician Reimbursement Rates Lag Medicare
Medicaid physician reimbursement rates in the fee-for-service part of the program were about 72% of Medicare rates for the same service, a new study finds. Continue Reading
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09 Feb 2021
AHA Decries UnitedHealthcare’s Diagnostic, Drug Coverage Policies
The hospital group urged CMS to step in to prevent the payers from implementing certain diagnostic and specialty pharmacy coverage restrictions. Continue Reading
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08 Feb 2021
Claim Automation Up, But $16.3B Remains in Potential Savings
Automation across 9 common claim transactions had increased in 2019, but key transactions like prior authorizations are still largely manual, CAQH reports. Continue Reading
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08 Feb 2021
Understanding 2021 Changes in Emergency Medicine Reimbursement
From surprise billing legislation to Medicare payment updates, emergency medicine reimbursement will face key changes in 2021 that will impact provider revenue. Continue Reading
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05 Feb 2021
Top Challenges, Opportunities of Medical Coding and Billing
COVID-19 impacted every aspect of medical coding and billing, but the challenges arising from the pandemic may reveal some key opportunities for improvement. Continue Reading
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04 Feb 2021
Hospital Claim Denials Steadily Rising, Increasing 23% in 2020
The average hospital claim denial rate continues to trend upward, with events like COVID-19 accelerating the growth, a new report shows. Continue Reading
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03 Feb 2021
Groups Want Medicare Sequester Moratorium Through End of PHE
More than 40 healthcare organizations are asking Congress to extend the pause on a 2% Medicare sequester through the end of the public health emergency. Continue Reading
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01 Feb 2021
Medicare, Medicaid Payments Off Actual Costs By $75.8B in 2019
The Medicare and Medicaid payment shortfall left hospitals underpaid for care delivered to beneficiaries right before the COVID-19 pandemic hit in early 2020. Continue Reading
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28 Jan 2021
CMS Failed to Flag Medicare Fee-for-Service Healthcare Fraud, Waste
From 2014 to 2017, CMS had an improper payment rate of 60.7 percent, accounting for $3.5 million in healthcare fraud, waste, and abuse. Continue Reading
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27 Jan 2021
Physicians Call for Fair Reimbursement for COVID-19 Vaccines
A new position statement from the American College of Physicians calls for adequate reimbursement from payers for all COVID-19 vaccines and their administration. Continue Reading
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26 Jan 2021
Hospital Uncompensated Care Costs Grew to $41.61B in 2019
Hospital uncompensated care costs were up from $41.3B in 2018 and $38.4B in 2017, revealing an upward trend, according to AHA data. Continue Reading
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20 Jan 2021
AMA Issues Unique CPT Codes for Janssen COVID-19 Vaccine
The single-dose COVID-19 vaccine from Janssen Pharmaceutica, a division of Johnson & Johnson, is the 4th vaccine candidate to get unique CPT codes for documentation and billing. Continue Reading
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15 Jan 2021
CMS to Reprocess Some Outpatient Claims After Site-Neutral Ruling
The agency said it will automatically start reprocessing claims impacted by the site-neutral payment policy upheld by an appeals court last year. Continue Reading
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12 Jan 2021
Clinicians, Tech Help St. Joseph’s Health Increase Charges by $39.6M
The safety-net health system improved charge capture through robust clinician education and engagement, with help from revenue cycle solutions. Continue Reading
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11 Jan 2021
CMS Recalculates Medicare Physician Fee Schedule Rates for 2021
The agency provided a 3.75% increase in overall Medicare Physician Fee Schedule payments for 2021 after a COVID-19 stimulus package reversed rate cuts. Continue Reading
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05 Jan 2021
OIG: Direct Wage Index Increases to Low-Margin Rural Hospitals
The HHS watchdog suggested that CMS target low-margin hospitals for new hospital wage index increases designed to support rural hospitals. Continue Reading
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21 Dec 2020
AMA Creates CPT Codes for AstraZeneca’s COVID-19 Vaccine
The COVID-19 vaccine has yet to be approved by the FDA, but is drawing closer to approvals in other countries, such as the United Kingdom. Continue Reading
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17 Dec 2020
HHS Doles Out $24.5B in Latest Provider Relief Fund Distribution
The federal department boosted the Phase 3 Provider Relief Fund distributions from the original $20B to satisfy close to 90% of lost revenues for over 70K providers. Continue Reading
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17 Dec 2020
US Healthcare Spending Hit High of $3.8T After Rising 4.6% in 2019
New data from CMS shows that national healthcare spending continued to increase at a quick pace in 2019, but that trend is likely to change in 2020. Continue Reading
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16 Dec 2020
Key Considerations for COVID-19 Vaccine Billing and Coding
Now that a COVID-19 vaccine is approved, providers need to execute a medical billing and coding strategy to sustain vaccination efforts. Continue Reading
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16 Dec 2020
Providers, Lawmakers Say #StopTheCuts to Physician Fee Schedule
Nearly 400 medical organizations and 329 lawmakers launched the #StoptheCuts campaign to get Congress to stop rate reductions to the Physician Fee Schedule slated for Jan. 1. Continue Reading
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15 Dec 2020
Hospitals File Lawsuit to Settle 340B Issues with Pharma
AHA and four other hospital groups are suing HHS after the department failed to respond when major pharmaceutical companies stopped providing 340B drug discounts earlier this year. Continue Reading
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14 Dec 2020
US Healthcare Spending Declines from COVID-19, But Remains High
Healthcare spending in the US is down by 0.5 percent so far this year, but high prices continue to make America one of the most expensive countries for healthcare. Continue Reading
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08 Dec 2020
Hospital Claim Denials Up for Most, Driven by Prior Authorizations
AHA reported that 89% of hospitals and health systems have experienced an increase in claim denials over the past 3 years, with 51% saying the increase has been “significant.” Continue Reading
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07 Dec 2020
CMS Provides Billing Codes for Regeneron’s COVID-19 Antibody Drug
The agency also released payment allowances for the two billing codes, which account for the injection, infusion, and post-administration monitoring of the recently approved COVID-19 antibody drug. Continue Reading
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04 Dec 2020
Hospitals Criticize Major Policy Moves in 2021 OPPS Final Rule
Industry groups are skeptical that policies in the 2021 OPPS final rule meant to spark competition will lead to lower costs, instead, they argue the policies will harm hospitals during the pandemic. Continue Reading
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01 Dec 2020
CMS Hospital At Home Model Seeks to Boost Capacity During COVID-19
CMS selected 6 health systems to participate in a hospital at home model; the agency also announced a new flexibility for some ambulatory surgery centers to expand hospital capacity during COVID-19. Continue Reading
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30 Nov 2020
New ICD-10 Codes, MS-DRG Assignments for COVID-19 Coming Jan. 1
CMS will implement 21 new ICD-10 procedure codes for COVID-19 vaccines and therapeutics; the agency also assigned MS-DRGs for 6 new ICD-10 diagnosis codes for conditions related to COVID-19. Continue Reading