In dental practices, where reimbursement cycles are tighter and administrative inefficiencies are immediately visible, AI is already being evaluated not for novelty, but for operational impact.
As providers continue to adopt AI in droves, payers are under pressure to modernize their own administrative operations. Alaffia Health says its clinically grounded AI platform can help health plans reduce waste and risk, a bet investors backed this week with a $55 million Series B funding round.
Zelis highlights how employers, payers, and consumers are integrating digital tools to manage healthcare costs.
Too often, providers handle all military claims the same way — sending them to the VA and hoping for the best. But there are multiple payer types, and they function very differently.
AI tools can work together across the payer value chain, exchanging information, collaborating and making autonomous decisions based on business rules. Here are just a few examples of how their bottom lines are benefiting.
How do we tip the scale to lower the rate of denials? While AI has been the initial decision-maker for years, it must become better trained. And to do that, it needs help.
Whether trying to see more patients, retain more staff, expand the organization’s technology stack or bring more dollars in the door, it’s not uncommon for professionals to want to maximize their resources amidst a market influx.
How to turn analytics into actual policy outcomes.
With these tools, therapists can reclaim their time, focus on their patients, and deliver the high-quality care that every individual deserves — all while maintaining the financial stability to thrive in their practices.
Three things drug manufacturers and CEs can do to build trust and enable effective collaboration
In a new lawsuit, Bon Secours Mercy Health Virginia alleges that Anthem Health Plans of Virginia owes the health system more than $93 million in outstanding unpaid and underpaid claims.
The California-based health system and insurer has bilked CMS out of "hundreds of millions of dollars" by submitting claims that were altered to make patients appear sicker than they were, a new complaint filed by the DOJ alleges. Kaiser denied these allegations saying it is confident in its compliance with Medicare Advantage program requirements.
By reducing administrative burden and redesigning workflows around human needs, it creates space for what matters most: connection between clinicians and patients.
UnitedHealthcare and United Behavioral Health agreed to the settlement to resolve allegations that they illegally denied coverage for mental health and substance use disorder treatments. The allegations are related to business practices they no longer use, parent company UnitedHealth Group said.
GS Labs, a Covid-19 testing provider, has submitted over $9.2 million in claims to the insurer as a result of its grossly inflated prices, the lawsuit states. The testing company rejected the claims, saying its "prices accurately reflect the level of service" it provides.
Per a policy update that went in to effect July 1, the health insurance giant is not covering non-emergency services that members receive at out-of-network facilities that are outside of their service area. This update mainly affects residential treatment facilities, inpatient rehabilitation and other non-hospital-based services.
UnitedHealthcare is instituting a new policy beginning July 1 that changes how the payer assesses emergency department claims, allowing it to retroactively deny ones it deems "non-emergent" or not an emergency. The American College of Emergency Physicians has made its opposition clear, stating the policy may violate federal law.
In a lawsuit filed three years ago, Aetna alleged that Mednax had overbilled for medical procedures and services. Now, the insurer is accusing the medical group of destroying evidence pertaining to the suit and has asked a federal court to sanction Mednax.