In dental practices, where reimbursement cycles are tighter and administrative inefficiencies are immediately visible, AI is already being evaluated not for novelty, but for operational impact.

The post What Dentistry Is Teaching Healthcare About Operational AI appeared first on MedCity News.

As providers continue to adopt AI in droves, payers are under pressure to modernize their own administrative operations. Alaffia Health says its clinically grounded AI platform can help health plans reduce waste and risk, a bet investors backed this week with a $55 million Series B funding round.

The post Alaffia Health Snags $55M for AI Engine Tackling Healthcare’s Waste Problem appeared first on MedCity News.

Too often, providers handle all military claims the same way — sending them to the VA and hoping for the best. But there are multiple payer types, and they function very differently.

The post Not All Military Payers Are the Same — And That Matters More Than Ever appeared first on MedCity News.

AI tools can work together across the payer value chain, exchanging information, collaborating and making autonomous decisions based on business rules. Here are just a few examples of how their bottom lines are benefiting.

The post How Health Plans Are Adding Up Real Value From AI appeared first on MedCity News.

How do we tip the scale to lower the rate of denials? While AI has been the initial decision-maker for years, it must become better trained. And to do that, it needs help.

The post Better AI + Correct Provider Guidance = Fewer Denials  appeared first on MedCity News.

Whether trying to see more patients, retain more staff, expand the organization’s technology stack or bring more dollars in the door, it’s not uncommon for professionals to want to maximize their resources amidst a market influx.

The post Want to Maximize Rev Cycle Efficiencies? Here are 3 Considerations appeared first on MedCity News.

With these tools, therapists can reclaim their time, focus on their patients, and deliver the high-quality care that every individual deserves — all while maintaining the financial stability to thrive in their practices. 

The post Therapists vs. Insurance: How AI Could End the Battle Over Mental Health Care 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.

In a new lawsuit, Bon Secours Mercy Health Virginia alleges that Anthem Health Plans of Virginia owes the health system more than $93 million in outstanding unpaid and underpaid claims.

The post Bon Secours Mercy Health Sues Anthem Health Plans of Virginia for Unpaid Claims appeared first on MedCity News.

The California-based health system and insurer has bilked CMS out of “hundreds of millions of dollars” by submitting claims that were altered to make patients appear sicker than they were, a new complaint filed by the DOJ alleges. Kaiser denied these allegations saying it is confident in its compliance with Medicare Advantage program requirements.

The post DOJ accuses Kaiser Permanente of Medicare Advantage fraud in new complaint appeared first on MedCity News.

UnitedHealthcare and United Behavioral Health agreed to the settlement to resolve allegations that they illegally denied coverage for mental health and substance use disorder treatments. The allegations are related to business practices they no longer use, parent company UnitedHealth Group said.

The post UnitedHealth subsidiaries settle mental health parity allegations for $15.6M appeared first on MedCity News.

GS Labs, a Covid-19 testing provider, has submitted over $9.2 million in claims to the insurer as a result of its grossly inflated prices, the lawsuit states. The testing company rejected the claims, saying its “prices accurately reflect the level of service” it provides.

The post BCBS of Kansas City sues Covid-19 testing provider over alleged price gouging appeared first on MedCity News.

Per a policy update that went in to effect July 1, the health insurance giant is not covering non-emergency services that members receive at out-of-network facilities that are outside of their service area. This update mainly affects residential treatment facilities, inpatient rehabilitation and other non-hospital-based services.

The post UnitedHealthcare nixes some out-of-network coverage for non-emergencies appeared first on MedCity News.

UnitedHealthcare is instituting a new policy beginning July 1 that changes how the payer assesses emergency department claims, allowing it to retroactively deny ones it deems “non-emergent” or not an emergency. The American College of Emergency Physicians has made its opposition clear, stating the policy may violate federal law.

The post Emergency physicians oppose new UnitedHealth policy enabling retroactive ED claims denial appeared first on MedCity News.

In a lawsuit filed three years ago, Aetna alleged that Mednax had overbilled for medical procedures and services. Now, the insurer is accusing the medical group of destroying evidence pertaining to the suit and has asked a federal court to sanction Mednax.

The post Aetna accuses Mednax of destroying evidence in overbilling suit: 5 things to know appeared first on MedCity News.

In a trial last year, a federal judge found that a UnitedHealth subsidiary had illegally denied mental health and substance use disorder claims. The same judge has now ordered the payer to reprocess all the claims and reform its guidelines.

The post UnitedHealth must reprocess thousands of illegally denied mental health claims, judge orders appeared first on MedCity News.

Four class action suits filed in early April accuse United Behavioral Health and Cigna Behavioral health of underpaying providers for mental health services. They allegedly used a third-party vendor called Viant to negotiate claims.

The post Lawsuits accuse United, Cigna of underpaying for behavioral health claims appeared first on MedCity News.