Since its inception, AI in prior auth has only been at work in the commercial healthcare marketplace. Now new innovative approaches that reframe prior auth as a resource instead of a roadblock have come to Medicare via the WISeR model.

The post ‘Prior Authorization’ Has Become a Dirty Word in Healthcare, But it Might Be Medicare’s Smartest Path Forward appeared first on MedCity News.

Billing frustration isn’t just a provider problem; it’s a patient problem too.
Every delayed claim, every error, every confusing denial ultimately affects the person receiving care. Now AI can reduce that friction.

The post The $25.7B Healthcare Problem AI Is Finally Solving appeared first on MedCity News.

Health systems should take the lead in fixing the broken prior authorization process, said Jeff Balser, CEO of Vanderbilt University Medical Center, during a recent conference. He highlighted AI, better workflows and centralized support as ways to reduce delays.

The post Vanderbilt CEO: Health Systems Can Fix Prior Auth Without Waiting for Payers appeared first on MedCity News.

The real story isn’t about denial rates or stakeholders acting as villains. It’s about a healthcare system that forces intelligent, well-intentioned professionals to make critical decisions in information silos.

The post Healthcare’s Data Orchestra: Why Rising Drug Denials Signal a Need for Better Coordination appeared first on MedCity News.

Medical coding startup Arintra raised $21 million in Series A funding to help hospitals and physician groups secure accurate, timely reimbursement. The company’s AI-powered platform automates coding, spots documentation gaps and generates claims tailored to specific payers.

The post Arintra Raises $21M to Help Providers Win the Reimbursement Fight appeared first on MedCity News.

While prior authorization has made many headlines over the past year, concurrent review has not. Yet missteps in both processes leave hospitals in danger of not getting paid, which can result in higher costs being passed down to patients. 

The post What is Concurrent Review? appeared first on MedCity News.

As AI has evolved to be more accurate and reliable, it’s become suitable for high-stakes use cases including automating health insurance verification.

The post The Patient Intake Revolution – How AI Is Eliminating Intake Busywork and Reducing Insurance Denials appeared first on MedCity News.

The choices we make now will determine not just the future of healthcare, but the kind of society we leave to our children. Will we continue to allow faceless algorithms to decide who lives and who suffers? Or will we finally reclaim healthcare’s moral center and build a system worthy of our highest values?

The post When Algorithms Decide Who Lives and Who Suffers appeared first on MedCity News.

Brian Thompson’s murder was chilling, but the social media response of this tragedy was equally shocking, if eye-opening. It shows a massive collapse of public trust in our healthcare system, a system so broken that it bankrupts families, denies life-saving care, and treats death as an acceptable cost of doing business.

The post A Healthcare System’s Moral Bankruptcy Goes Viral appeared first on MedCity News.

Hospitals are facing increasingly burdensome policies from commercial insurers, leading to problems with cash flow and patient safety. Hospital executives think federal regulators need to enact stricter policies that require payers to operate on faster timelines, as well as provide more transparency into their reasons for denying claims.

The post Payers Are Putting Profit Over Patients with Denials and Prior Auth Policies, Hospitals Say appeared first on MedCity News.

Focusing on these areas can help healthcare organizations reduce the incidence of denials, optimize revenue cycle performance and enhance overall patient satisfaction. 

The post Transforming Denials Management: Insights and Best Practices for Your Organization appeared first on MedCity News.

Insurers should immediately end their overreach into medical decision-making and work with medical providers and their patients to ensure timely care for all.

The post Insurer “Delay and Deny” Practices Continue to Threaten Patients’ Timely Access to Gastrointestinal Care – It’s Time for Reform appeared first on MedCity News.

Here are six actionable steps healthcare organizations can take to reduce their likelihood of denials and write-offs.

The post The Top Strategies Healthcare Organizations Can Use to Reduce Denials appeared first on MedCity News.

The combination of technology and cross-functional collaboration allows providers to address denials and achieve optimal revenue performance.

The post Breaking Silos: The Power of Collaboration in Minimizing Denials for Better Revenue Cycle Performance appeared first on MedCity News.

Health systems have been increasingly dropping MA contracts, saying that they cause their organizations to lose too much money and result in dangerous patient care delays. To mitigate this issue, experts think large MA plans need to delegate more utilization management duties to health systems rather than handling it themselves.

The post Who Really Benefits From Medicare Advantage Plans? appeared first on MedCity News.

Brian Gragnolati, CEO of Atlantic Health System, said that “there’s a war going on between providers and payers right now.” In his view, payers “are doing everything they can” not to pay providers for the care they deliver. He said insurers have greatly increased their rate of denials and are extremely reluctant to take on risk in value-based contracts.

The post Payers and Providers Are at War, Atlantic Health System CEO Says appeared first on MedCity News.

Compared to government payers, commercial payers take significantly longer to pay hospitals and deny claims at a higher frequency — often without a justifiable reason to do so — according to a new report. Commerical payers have better reimbursement rates than government payers, but providers often have to wait 90 days or more get claims paid by commercial plans.

The post Commercial Payers’ Rising Claims Denials Rates Are Exacerbating Hospitals’ Financial Woes appeared first on MedCity News.

Health insurers are prohibited from placing unfavorable limits on mental health and substance abuse benefits, and yet, many do. Federal and state regulators are taking aim at these practices and making the enforcement of the Mental Health Parity and Addiction Equity Act of 2008 a key focus.

The post Coverage parity for mental health, substance abuse, a key focus for insurance regulators appeared first on MedCity News.