Claims Adjudication

Texas-based study raises questions about impact of using additional criteria in No Surprises Act arbitration cases

Study results indicate that ongoing litigation over the independent dispute resolution process established by the No Surprises Act may not have a major impact on outcomes.

Nick Hut June 22, 2022

Utilization review staff may be hurting results when fixing incorrect inpatient admissions

There's a clear financial winner when choosing a method for correcting an incorrect inpatient admission.

Ronald Hirsch, MD June 9, 2022

Some Medicare payments to hospitals for bariatric surgery may be inappropriate, OIG finds

Medicare could have saved nearly $48 million in bariatric surgery payments to hospitals during an 18-month period if coverage rules and guidance were better implemented at the contractor level, according to the HHS Office of Inspector General.

Nick Hut May 17, 2022

Big delays could be in store for early No Surprises Act arbitration cases

The portal for payment arbitration cases taking place under the No Surprises Act is open for business but could be facing a backlog of cases.

Nick Hut May 9, 2022

Tentative deal to provide pandemic funding won’t replenish the COVID-19 Uninsured Program

A bipartisan Senate bill would pay for additional vaccines and therapeutics but wouldn’t restore funding to a program that reimburses providers for furnishing COVID-19-related services to the uninsured.

Nick Hut April 27, 2022

Claims submitted to HRSA’s COVID-19 funds for uninsured and underinsured patients soon won’t be paid

Funds used to reimburse providers for supplying COVID-19-related services to the uninsured and underinsured will expire soon if Congress doesn’t act.

Nick Hut March 31, 2022

8 ways healthcare providers can smooth the DRG audit process

A health system’s financial sustainability depends on its being paid appropriately for the services it delivers. Yet routine payer audits can all too often result in downgrades of a health system’s billed diagnosis-related groups (DRGs), resulting in lower payment. It therefore behooves health systems to be well prepared for such audits and thoroughly understand why payers’ are most inclined to take such action.

Lauren Coleman February 25, 2022

Federal judge rules for providers in a case about a key component of the new surprise billing regulations

A federal judge found in favor of the Texas Medical Association in a case about the arbitration process that is being implemented as part of the No Surprises Act.

Nick Hut February 25, 2022

Coverage denials based on medical necessity are far more likely to arise from Medicare FFS rules than from MA plan policies

Coverage rules stemming from Medicare national and local determinations were the most likely cause of claim denials in one Medicare Advantage plan.

Nick Hut January 18, 2022

Research highlights ways to save more than $250 billion per year through healthcare administrative simplification

Savings can be generated at the organizational and healthcare industry levels through steps to reduce wasteful administrative processes, study authors wrote.

Nick Hut October 22, 2021
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-leaderboard' ); } );