By using AI-powered intelligence to shift clinical and coding validation earlier in the healthcare continuum, and unlocking upstream clinical data to inform downstream payment workflows, organizations can proactively prevent errors, reduce downstream churn and friction, and support more predictable, accurate, and timely payments. 

The post The Next Era of Payment Integrity: Earlier Clinical Validation, True Transparency appeared first on MedCity News.

Rather than using AI to compete, we must design AI to collaborate. As the regulatory landscape evolves and industry pledges push for real-time, electronic, and transparent authorizations, the imperative is clear: technology must bridge the payer-provider divide, not widen it.

The post AI Is Fueling a New Arms Race in Healthcare: Here’s How We Stop It appeared first on MedCity News.

[Sponsored] Zelis highlights, through a recent survey, how employers, payers, and consumers are integrating digital tools to manage healthcare costs. The findings provide a comprehensive view of the healthcare financial landscape, bringing together stakeholder perspectives, priorities and the opportunities to address them.

The post Survey on the Healthcare Financial Landscape Offers a Roadmap for Stakeholders appeared first on MedCity News.

The real promise of AI agents lies not in their intelligence but in their ability to deliver empathy at scale. By taking on repetitive tasks and restoring capacity to the people who deliver care, AI can help rebalance the system toward its original, deeply human purpose.

The post Actionable AI in Clinical Settings: Trust and Transparency as the Core Operating System appeared first on MedCity News.

Confirmed diversion cases do not equal true prevalence – they are directly dependent on investigative proficiency, tooling, and the bandwidth of the teams doing the work.

The post The Illusion of Diversion Data: Why Confirmed Diversion Counts Misrepresent True Risk appeared first on MedCity News.

At a time when 98 million prescriptions are abandoned due to cost surprises, it’s critical that all four categories of prescription drug prices are available so consumers can determine how to obtain needed medications at the lowest cost.

The post Medication Affordability Depends on Total Price Transparency appeared first on MedCity News.

As healthcare data explodes, agentic AI has emerged as a solution to validate medical information through specialized agents working together behind the scenes.

The post Agentic AI: Shifting Medical Affairs from What’s Happening to Why appeared first on MedCity News.

While there is a significant need and opportunity to address this overall spend with advanced AI tools that predict patient needs and readmission likelihood, intrinsic biases within these algorithms ultimately cause more harm than good and financial savings are being achieved at the expense of patient’s health. 

The post AI Decides Who Gets Care: Tackling Bias in AI Coverage Decisions appeared first on MedCity News.

We are building a more connected system that bridges acute and post-acute settings by uniting insights across the continuum. The insights empower clinicians with the information they need at the moment they need it, resulting in faster, safer, and more human-centered care.

The post How AI Is Reshaping Emergency Departments appeared first on MedCity News.

CMS and AHIP are raising the floor, but forward-thinking plans are aiming higher. They’re designing utilization management systems that are clinically sound, operationally efficient, and aligned with enterprise goals.

The post Why Health Plans Are Reclaiming Utilization Management, and What It Takes to Do It Right appeared first on MedCity News.

Despite all the noise around the updates, there’s one area that’s been conspicuously absent this year: enforcement of patient estimate requirements.

The post Price Transparency Enforcement Is Still A Shared Responsibility appeared first on MedCity News.

Leading in healthcare when the odds are stacked against you is not about eliminating the challenges. It is about meeting them without losing sight of the reason we chose this profession in the first place.

The post Leading Quality Care When The Odds Are Stacked Against You appeared first on MedCity News.

Health care in the United States is confusing for patients and consumers. Price transparency is a step in the right direction — transformative change can happen by combining cost, quality, appropriateness and efficiency measures.

The post Healthcare Price Transparency is Not Enough appeared first on MedCity News.

Here are five guidelines to help employers balance health outcomes and financial responsibility to ensure that GLP-1 coverage is effective, affordable, and aligned with improved health and workforce well-being for employees and their families.

The post How Employers Can Build an Effective GLP-1 Strategy appeared first on MedCity News.

This new standard was developed to address the rise of telehealth, cybersecurity risks/compliance in ePrescribing, data needs, AI, and the growing demand for patient transparency. So what is the Standard solving for, and what can providers expect?

The post What Providers Need to Know About the Coming NCPDP Transition appeared first on MedCity News.

Imagine360 has launched a new product called Complete Care, which includes a pharmacy benefit solution named Imagine360Rx.

The post Imagine360 Unveils New Product To Provide Employers More Transparency appeared first on MedCity News.

Those who recognize that AI governance is an innovation enabler will be able to align business priorities and AI investments — and make smarter decisions about which models to accelerate, and which to retire — ultimately leaving the enterprises better positioned to achieve ROI on their AI.

The post AI Governance: Building Trust and Transparency for Healthcare AI appeared first on MedCity News.

By reimagining the payment experience through transparency, flexibility, and technology, providers can drive better outcomes for both their bottom line and the patients they serve.

The post Improving Patient Payment Collections: Strategies for Success appeared first on MedCity News.

As real-time inference overtakes training-centric approaches, a pivotal question emerges: how can the human element remain central in an increasingly autonomous ecosystem?

The post The Future of AI in Healthcare Demands Transparency, Trust, and Human-Centered Design appeared first on MedCity News.

As an industry, we can and must do more. To be truly actionable, prices must be easily accessible, understandable, and patients need to be actively engaged to act on that information.

The post Healthcare Price Transparency is More Than Showing a Price Tag appeared first on MedCity News.

Kennedy emphasized that these inefficiencies aren’t just administrative headaches, they’re costing lives. Nowhere is this more evident than in organ-transplant logistics: the way organs get assigned – and move – from donors to patient recipients.

The post RFK’s Hearing: Inefficiencies in Government-Controlled Systems appeared first on MedCity News.

Certified clinicians and therapists have specific ethical foundations and analytic responsibilities to uphold that might not apply to all members of the healthcare field.

The post Understanding the Ethics of AI in ABA Therapy appeared first on MedCity News.

Running a behavioral health practice requires balancing patient volume and case diversity, while maintaining operations. Transparent practice policies are necessary for success and ensuring high-quality, consistent patient care.

The post 4 Practice Policies that Help Maintain Behavioral Health Practice Success appeared first on MedCity News.

Like any other tool, understanding the right problem to apply it to is the difference between success and failure. Addressing a problem is never just about technology; it’s always about people, processes, and technology. 

The post The AI Advantage: Reimagining the Future of Drug Development  appeared first on MedCity News.

Focusing on comprehensive strategies and embracing flexible technology solutions arms pharmacy leaders to stay ahead of industry changes, connect teams, and integrate information efficiently. 

The post 10 Imperatives of a Medication Intelligence System to Streamline the Pharmacy Lifecycle appeared first on MedCity News.

We can’t wait for others to find a solution to high drug prices. It’s clear what should happen in a functioning drug pricing market federally and in California, but it is not happening today.

The post Three Ways Drug Pricing Should Work in a Functioning Market, But Isn’t appeared first on MedCity News.

With so much to consider, avoiding hidden and often astronomical costs is a top priority for healthcare leaders. Understanding the totality of an EHR vendor’s offering is crucial, especially since vendors do not cover all the costs of their solutions similarly.

The post Avoiding Surprises – Five Key Questions to Ask When Evaluating an EHR Vendor appeared first on MedCity News.

Three things drug manufacturers and CEs can do to build trust and enable effective collaboration

The post How Covered Entities and Pharma Companies Can Better Collaborate on Drug Discount Programs appeared first on MedCity News.

Micky Tripathi, head of The Office of the National Coordinator for Health Information Technology (ONC), thinks his office’s recent rule on AI transparency will spur greater adoption of AI tools in healthcare, as well as potentially drive higher quality AI-based products.

The post ONC Chief: New AI Transparency Rule Should Drive Higher Quality Tools & More AI Adoption appeared first on MedCity News.

Last week, HHS finalized a new rule that requires healthcare AI developers to provide more data about their products to customers, which could aid providers in determining AI tools’ risks and effectiveness. Some AI leaders believe the new guardrails are a step in the right direction, and others are skeptical about whether the new rules are necessary or will be effective.

The post How Are AI Companies Reacting to HHS’ New Transparency Requirements? appeared first on MedCity News.