Claims Processing

Claims processing involves both healthcare payers and providers, and relies heavily on the use of IT systems to submit, receive and either approve or deny payment. Disrupted processing can subject providers to cost increases associated with inefficiency and outstanding balances. Hospital billing departments use billing and revenue cycle management systems to get claims processed and paid in the most timely and efficient manner possible.

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Medicare announced Friday that it was revising rules intended to prevent the agency from paying twice for the same prescriptions for seniors receiving hospice care. The drug categories in question were identified in a 2012 investigation by the HHS inspector general.
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Post date: July 21, 2014
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If your modus operandi is to appeal all denied claims, you may want to reconsider because some claims are not worth it.
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Post date: July 8, 2014
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Of the states that built their own health insurance exchanges that are now operational, Washington, Kentucky and Minnesota enjoyed some successes that might be replicated.
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Post date: June 12, 2014
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The American Hospital Association is asking federal Medicare leaders to stem the practice of using sample hospital audit data to extrapolate overpayments eligible for recovery. The lack of clarity regarding standards for short patient stays has clouded the issue.
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Post date: June 4, 2014
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For the second year in a row, Humana ranked first in overall performance among 148 payers, according to the 2014 PayerView Report. The report ranks health insurers according to specific measures of financial, administrative and transactional performance.
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Post date: May 28, 2014
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The federal government and a number of hospitals may want to transition to a new Medicare reimbursement model. But there are still billions of dollars in disputed fee-for-service claims waiting to be settled, sowing animosity between health systems and the feds.
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Post date: May 27, 2014
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A new interpretation of a 40-year-old law could offer healthcare providers more options for appealing payer recoupments or preventing them altogether.
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Post date: May 21, 2014
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A number of changes have affected the success of subrogation in the healthcare insurance setting -- changes that financial executives need to be aware of in order to both mitigate negative impact and maximize opportunities.
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Post date: May 14, 2014
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With Medicare's "two midnight rule" set to take effect later this year and audit appeals facing lengthy backlogs, the Recovery Audit Contractor program may be headed in some new directions.
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Post date: April 1, 2014
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When it comes to patient collections at small, community hospitals, the process can be much the same as at larger hospitals around the country, with one exception.
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Post date: March 25, 2014
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An unusual 90-day grace period for government-subsidized health plans may leave physicians at risk for not getting paid for their services.
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Post date: March 20, 2014
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The financial impact of the two midnights rule remains an open question and so is whether recovery auditors will challenge fewer claims or just shift their focus.
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Post date: March 17, 2014
News
One of the worst failures of the Affordable Care Act is that, even with subsidies, the premiums and out-of-pocket expenses are unaffordable for far too many people. Unfortunately, a new proposal for catastrophic plans with very high deductibles would make accessing healthcare truly unaffordable for even more people.
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Post date: June 16, 2014
Blog
With Congress delaying the date for ICD-10 compliance to Oct. 1, 2015, you have a great opportunity to re-assess your organization's implementation progress. Make sure these six crucial tasks are on your ICD-10 punch list.
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Post date: June 9, 2014
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One of the major arguments against the ICD-10 transition are the financial costs to medical practices. Sure, there are accusations of bureaucratic overreach, but the anti-ICD-10 argument is primarily financial. So why not offer providers an incentive?
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Post date: May 28, 2014
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On Oct. 1, 2013, I marked the 12-month countdown to ICD-10 implementation by attempting to answer some basic questions. Now that more than six months have passed, and we have another deadline delay, many healthcare providers still can't get satisfactory answers.
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Post date: May 20, 2014
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It has never been clearer: physician practices must be able to code in ICD-10 to bill for services and procedures after Oct. 1, 2014, or they will see a cash flow interruption, additional costs and delayed claims payments. But payers, clearinghouses and vendors can help you.
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Post date: March 11, 2014
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There's still plenty of work to do before the Oct. 1 ICD-10 deadline. A recent study found that only 4.8 percent of physician practices reported significant progress in overall ICD-10 readiness. Hospitals report higher levels, but many are still behind.
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Post date: March 3, 2014
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Healthcare is one of the last bastions of consumer-unfriendly billing and pricing. As individuals start to take on more responsibility for premiums, deductibles and co-pays, they are increasingly demanding more transparency. And providers will be forced to respond.
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Post date: February 27, 2014
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Conventional wisdom says that too many ICD-10 codes will make it harder for clinicians and medical coders to do their jobs. Some studies suggest a 50 percent or more drop in productivity. But is this an underestimation of the problem?
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Post date: February 17, 2014
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A disconnect occurring in the fraud identification process used by CMS could mean that legitimate claims may be flagged as possible fraud.
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Post date: January 28, 2014
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If you haven't figured out an ICD-10 transition budget yet, it may be too late. But it's a good idea to get a handle on what it will cost you. Better late then never.
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Post date: January 16, 2014
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While the past year was relatively tame regarding ICD-10, at least in regard to the mad scramble some expect leading up to October 1, 2014, there were some significant developments.
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Post date: December 30, 2013
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I don't mean to pick on healthcare IT vendors, but they're going to be in for some tough criticism in 2014, according to the results of a Workgroup for Electronic Data Interchange ICD-10 survey.
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Post date: December 26, 2013
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