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Prior Authorization and Denials
Prior Authorization and Denials in Medicare Advantage: the news, the names and what changed.
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Latest in Prior Authorization and Denials
29 Health Systems Dropping Medicare Advantage Plans
5+ day, 17+ hour ago (872+ words) The number of terminated contracts this year is down from 40 in 2025 and 32 in 2024, Becker’s Hospital Review reported on Sept. 4. Naples Comprehensive Health, one of the top 50 U.S. hospitals, will go out of network with Centene’s Wellcare and Health Care Service…...
How Medical Denial Management Actually Works (And Why Most Practices Get It Wrong)
1+ day, 14+ hour ago (31+ words) Claim denials cost healthcare practices more than most providers realize — not just in lost revenue, but in staff …...
Guest Commentary | ‘Prior authorization’ remains a pain point for physicians, patients
3+ day, 8+ hour ago (382+ words) Physicians devote the early part of their careers to education and training. They spend years honing and refining their clinical skills through medical school, internships, residencies and fellowships. Finally, they are ready and eager to step out on their own…...
157 Lab Providers Lost Medicare Billing Privileges—Here’s Why Checking Your Medicare Statement Matters
3+ day, 16+ hour ago (192+ words) According to CMS, those systems look for abnormal combinations involving testing, results, billing, documentation, and relationships that could indicate fraud, waste, or abuse. The technology can help flag high-risk claims for additional review and potentially allow claims to be held,…...
Medicaid Risk Contracts in New ACO LEAD Model
3+ day, 16+ hour ago (223+ words) Integrated care programs for dual-eligible beneficiaries, including ACO LEAD, aim to incentivize efficient care delivery while preventing unintended cost shifting between Medicare and Medicaid. How LEAD calculates shared savings and losses will be central to achieving both goals. First, a…...
Advantage Plans Said No 4.1 Million Times in 2024. Four in Five Appeals Won. Nine in 10 Denials Were Never Appealed.
3+ day, 18+ hour ago (629+ words) Medicare Advantage plans denied millions of prior authorization requests last year, and most patients accepted that answer without a fight. What happened to the ones who pushed back reveals something uncomfortable about how those first decisions get made. The Full…...
How to bridge insurance coverage gaps & save on prescriptions
4+ day, 15+ hour ago (40+ words) Yahoo Divya Iyer, Consumer Healthcare Expert and Senior Vice President at GoodRx, joined us to discuss how rising out-of-pocket costs and deductibles leave many insured Georgians facing health insurance coverage gaps....
A Vision for Modernizing Medicare Risk Adjustment: Building the Evidence for Reform
4+ day, 14+ hour ago (231+ words) Margolis Institute for Health Policy A Vision for Modernizing Medicare Risk Adjustment: Building the Evidence for Reform Medicare Advantage (MA) is the largest source of Medicare coverage for seniors today and continues to grow. The most important payment policy underpinning…...
A Medicare policy designed to encourage certain business arrangements produced unexpected results
4+ day, 17+ hour ago (393+ words) "The exclusion bar can be for the rest of your lifetime or for several years, but it effectively halts your ability to participate," said Alice Harris. Terry Gerton The Health and Human Services Department recently delegated one of its powers…...
New Records Reveal Problems with Medicare’s AI Prior Authorization Experiment
4+ day, 18+ hour ago (497+ words) EFF’s FOIA request sought records pertaining to the CMS contracts with WISeR software vendors; any tests for accuracy, bias, or hallucinations in vendors' technology; and any audits, monitoring, or evaluation of WISeR and participating vendors. CMS records obtained by EFF…...