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.

The real issue isn’t one payer, one policy or one bad actor. It’s a deeply fragmented system built on competing incentives, misaligned responsibilities and layers of administrative friction. 

The post Caught in the Middle: Unraveling Payer-Provider Blame in United States Healthcare appeared first on MedCity News.

The future of telehealth is trust, combined with patient education. As the market matures, all parties — providers, regulators, and platforms — must collaborate to sustain that trust. 

The post Telehealth Fraud & Compliance: Preventing ‘Pill Mills’ While Ensuring Access to Care appeared first on MedCity News.

AI can be a highly effective tool for plans aiming to reduce fraud, waste and abuse, but only if it is combined with investigative intelligence.

The post AI: A Good Tool to Combat Bad Actors in Healthcare appeared first on MedCity News.

Business and compliance considerations for MSOs and PCs, the contractual structure, and general recommendations for establishing a model that runs efficiently and mitigates levels of risk

The post “Friendly” PC Models: Key Contractual and Compliance Considerations appeared first on MedCity News.

By being aware of the latest schemes, health plan leaders can ensure their members have appropriate access to care while preventing bad actors from exploiting telehealth policies established during the pandemic.

The post Mental Health Fraud Schemes: How to Protect Your Plan appeared first on MedCity News.

Coordination of benefits is a critical pillar of the Medicaid program as it ensures the efficient use of resources, prevents overutilization, promotes equity in resource distribution, mitigates fraud and abuse, contributes to program longevity and ultimately enhances healthcare access for beneficiaries.

The post Coordination of Benefits: An Overlooked Pillar of Medicaid Programs appeared first on MedCity News.

Emblem Health’ s chief financial officer knows that prior authorization — where patients have to get advance clearance for a procedure from their insurance companies through their providers — can be frustrating. But in an interview at the Total Health conference organized by Reuters Events in Chicago on Thursday, she rejected the notion that the […]

The post How Emblem Health’s CFO is looking at reforming prior authorization appeared first on MedCity News.

Seniors’ demand for Medicare Advantage plans shows no signs of slowing down any time soon, and that means CMS is likely to continue accelerating its FWA audits of MA plans, particularly given the prevalence of Covid-19-related fraud.

The post A looming reckoning: Medicare Advantage audits will spike as feds scope out Covid-19 fraud appeared first on MedCity News.

Although telehealth offers many benefits for patients, it introduces operational complexities for providers and creates legitimate concerns about fraud, waste and abuse for payers.

The post How payment integrity tools can help payers to tackle fraud, waste and abuse appeared first on MedCity News.

A new study evaluating waste in the U.S. healthcare system identified six areas of wasteful spending and how cost curtailment efforts are ongoing there.

The post New JAMA study finds administrative complexity as the single-largest source of wasteful spending appeared first on MedCity News.