Claims & Payment Integrity
Expert articles and analysis related to claims & payment integrity.
AI Summary — Last 7 Days
Synthesis:
Over the past week, payment integrity and reimbursement tensions have intensified as CMS halted the BALANCE model due to insufficient payer interest, underscoring ongoing participation challenges in new value-based experiments. Meanwhile, a $117.7 million false claims settlement with Aetna over Medicare Advantage highlights scrutiny on data accuracy amid rising expenses for health plans, with Elevance booking a $935 million charge to address potential Medicare Advantage payment liabilities. Plans and providers are increasingly adopting standardized electronic prior authorization and leveraging AI tools to enhance payment accuracy and care management, but delays and provider frustration persist, pointing to friction between cost containment, innovation, and administrative burden for value-based care stakeholders. Key sources: CMS halts BALANCE model, [Aetna MA false claims settlement](https://news.google.com/rss/articles/CBMikgNBVV95cUxOV
Related Articles
Why health care fraud detection requires payment integrity alignment
In one health care organization, a provider was reviewed and cleared through routine payment integrity processes. Months later, that same provider became the subject of a fraud investigation, based on...
4 shifts that define the revenue cycle of the future
AI can improve patient access, coding, billing, and payment, but CFOs need a revenue cycle operating model built for scale, trust, and governance. The post 4 shifts that define the revenue cycle of th...
The Next Era of Payment Integrity: Earlier Clinical Validation, True Transparency
The Next Era of Payment Integrity: Earlier Clinical Validation, True Transparency MedCity News
Startup Helping Providers Manage Denied Claims Raises $16M
Startup Helping Providers Manage Denied Claims Raises $16M MedCity News
Protecting our pay against downcoding is a top issue for family medicine - American Academy of Family Physicians | AAFP
Protecting our pay against downcoding is a top issue for family medicine American Academy of Family Physicians | AAFP
The evolution of the revenue cycle builds on today’s multimodal approach
Multimodal AI in revenue cycle helps providers reduce cost to collect and streamline payer-provider communication across workflows. The post The evolution of the revenue cycle builds on today’s multim...
NYT: Provider-Driven Abuse An ‘Expensive Unanticipated Consequence’ of No Surprises Act
NYT: Provider-Driven Abuse An ‘Expensive Unanticipated Consequence’ of No Surprises Act AHIP
AI can help overcome both provider and payer inefficiencies
How the DOJ Is Tackling Fraud in the ACA Marketplace
How the DOJ Is Tackling Fraud in the ACA Marketplace MedCity News
Amperos Health secures $16M in series A funding, unveils AI-native denial management solution
Amperos Health secures $16M in series A funding, unveils AI-native denial management solution Fierce Healthcare