This week’s healthcare news highlights concerns that the latest rule defining electronic health record (EHR) requirements under the Medicare Access and CHIP Reauthorization Act’s (MACRA) alternative payment model may create administrative burdens for small healthcare IT vendors, the Centers for Medicare & Medicaid Services’ (CMS) latest plan to reward quality in its payment methodology for Medicare services, and a nine percent increase in the number of expected enrollees in the Affordable Care Act (ACA) health insurance marketplace.... Read More
In a recently released article from Kaiser Health News, Verscend senior vice president of risk adjustment Sean Creighton weighs in on industry concerns that under the Affordable Care Act (ACA), plans with greater administrative costs and higher premiums are succeeding disproportionally over lower-priced plans. Many exchange participants are calling for the Centers for Medicare & Medicaid Services (CMS) to take a closer look at how the risk adjustment formula is creating an environment in which “the rich get richer and the poor get poorer.” In the article, Creighton contends that “the industry complaints warrant a closer look,” adding that it might make sense to drop the average statewide premium from the formula and focus more directly on a health plan’s medical claims.... Read More
This week’s healthcare news looks at how a new pilot program from the Centers for Medicare & Medicaid Services (CMS) gives insurers more flexibility in benefit design, a tool to help providers implement MACRA, how doctors outperform algorithms in diagnosing patients, and a push by providers to prevent surprise bills for out-of-network services.... Read More
Verscend is celebrating the 20th anniversary of DxCG, the leading risk adjustment and predictive modeling tool in the industry. We recently published a new white paper, “The Evolution of DxCG, the Gold Standard in Risk Adjustment and Predictive Modeling.” In the white paper, we take a look at DxCG’s history and its importance in advancing the science of risk adjustment and predictive modeling in healthcare. For this week’s and next month’s industry influences blog we are featuring content from the white paper, which can be viewed in its entirety on our knowledge bank.... Read More
This week’s healthcare news highlights the Centers for Medicare & Medicaid Services’ (CMS) selection of Medicare Advantage insurers for its value-based insurance design model, concerns over claim denials as the ICD-10 grace period ends, and employers’ participation in the push toward value-based healthcare.
After years of focusing efforts on speeding up automated claim processing, most payers’ claim review systems have unintentionally let their guard down. As a result, improper outlier claims common to our industry continue to pass through automated systems right in plain view without getting flagged. For some payers, the impact can really sting, amounting to millions of dollars. Our latest infographic explores some of the most blatant examples of incorrect billing practices still going on today and what they may be costing you in inappropriate payments if not addressed.
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This week’s healthcare news takes a look at pushback against the Hospital Star Rating system released by the Centers for Medicare & Medicaid Services (CMS), a new guide designed to help providers find the right electronic health record system (EHR), a survey that shows how physicians’ outlooks are impacting their ability to adapt to healthcare reform, the latest on U.S. healthcare performance compared to other nations, and action from this week’s Verscend Health Conference (VHC16).... Read More
This week’s healthcare news takes a look at new health plan ratings released by the National Committee for Quality Assurance (NCQA), a comparison of premiums between Affordable Care Act (ACA) plans and employer-sponsored plans, what virtual reality technology is doing for healthcare providers and patients, and an evaluation of the Centers for Medicare & Medicaid Services’ (CMS) bundled payment initiative.... Read More
The cost of healthcare continues to dominate headlines as the Affordable Care Act (ACA) expands managed care, and thus provides fraudsters with new opportunities to take advantage of the system. This new and complex healthcare landscape—along with its varied payment methodologies—has forced insurers to work more aggressively to contain their costs. One of the ways in which insurers can respond to this changing healthcare environment and address fraud, waste, and abuse (FWA) is by reducing billing errors.
This week’s healthcare news highlights the latest data from the U.S. Census Bureau that shows insurers have spent more on healthcare this year compared to last year, news from the Centers for Medicare & Medicaid Services (CMS) that avoidable hospital readmission rates have fallen by 8 percent since 2010, and an update on CMS’ newly proposed options for the Medicare Access and CHIP Reauthorization Act (MACRA).... Read More