Dispute resolution likely to be more disruptive as a result of new rule
A recently released CMS final rule concerning independent dispute resolution (IDR) mediation likely will cause a further bottleneck of No Surprises Act-based appeals, experts said. In the final rule, the fees were set at $15, down from $115 paid before the proposed rule came out. CMS in its proposed rule had originally set the revised…
Health systems approach risk with payers
Health systems are finding different interest and approaches to downside risk in value-based care (VBC) among health plans in their markets. Mark Bortnem, CFO of Essentia Health, said some of their payers have clinical teams that will partner with Essentia’s medical leadership to strategize collectively about how to reduce low-value care and avoidable care. However,…
Cutting through the clutter: Practical strategies to reduce administrative waste in payer-provider interactions
Administrative costs in healthcare continue to rise, often consuming more resources than direct patient care. Nowhere is this more visible, or more solvable, than within revenue cycle management (RCM). These costs are not just a patient care concern; they strain the workforce and directly impact financial sustainability. Much of the challenge stems from a persistent…
For-profit health systems turn to AI and automation to manage payer denials
Some for-profit health systems are increasingly looking to AI and other automation tools to tackle the worsening problem of payer denial management, as 73% of providers have seen claims denials increase.
Report: Payer requests for information are slowing reimbursement
Payers are increasingly rejecting claims through requests for information (RFI) that in total serve no purpose other than to delay reimbursement, according to “Death by a thousand requests,” a report from consulting firm Kodiak Solutions. RFI claim denial rates as a percentage of total billed charges climbed to 3.82% in 2024 through May, up from…